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A nurse is caring for a laboring person who is receiving oxytocin for induction of labor. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate continuously
- B. increase maternal hydration
- C. administer IV fluids
- D. assess uterine tone
Correct Answer: C
Rationale: The correct answer is C because administering IV fluids is crucial during oxytocin infusion to prevent maternal dehydration and maintain fluid balance. This helps prevent complications such as uterine hyperstimulation and fetal distress. Monitoring fetal heart rate continuously (choice A) is important but not the priority. Increasing maternal hydration (choice B) is beneficial but does not address the immediate need for fluid replacement. Assessing uterine tone (choice D) is important but secondary to ensuring adequate hydration.
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The nurse is teaching a pregnant patient about prenatal vitamins. Which statement by the patient indicates that further teaching is needed?
- A. I will take these vitamins every day as prescribed.
- B. I will stop taking these vitamins if I feel nauseous.
- C. I should take prenatal vitamins to help prevent birth defects.
- D. These vitamins will help my baby grow and develop properly.
Correct Answer: B
Rationale: The correct answer is B. The rationale is that stopping prenatal vitamins if feeling nauseous can deprive the baby of essential nutrients crucial for proper development. Nausea is common during pregnancy, and it's important to continue taking prenatal vitamins to ensure the baby receives necessary nutrients. Choices A, C, and D all demonstrate understanding of the importance of prenatal vitamins in supporting the baby's growth and preventing birth defects.
What is the priority nursing action when a postpartum person experiences a boggy uterus after delivery?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. administer an analgesic
- D. administer pain medication
Correct Answer: B
Rationale: The correct answer is B: administer a uterotonic medication. This is the priority nursing action because a boggy uterus indicates uterine atony, which can lead to postpartum hemorrhage. Uterotonic medications help the uterus contract and reduce bleeding. Performing fundal massage (A) can be done after administering the medication to aid in uterine contraction. Administering an analgesic (C) or pain medication (D) is not the priority as the main concern is preventing excessive bleeding.
A nurse is caring for a laboring person who is experiencing late decelerations in fetal heart rate. What is the priority nursing intervention?
- A. place the person on their left side
- B. apply oxygen via mask
- C. administer pain medication
- D. perform a vaginal examination
Correct Answer: A
Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.
The nurse is caring for a pregnant patient who is 36 weeks gestation and is concerned about the upcoming delivery. Which of the following statements by the nurse is most appropriate?
- A. Labor will likely be quick and easy, especially since this is your first pregnancy.
- B. Labor can be unpredictable, and each birth is different.
- C. You will probably need a cesarean section since you are at full term.
- D. You may not feel any pain during labor because of modern pain relief options.
Correct Answer: B
Rationale: The correct answer is B: "Labor can be unpredictable, and each birth is different." This response acknowledges the variability and individuality of labor experiences, providing reassurance to the patient. Labor outcomes depend on various factors such as maternal health, baby's position, and other unforeseen circumstances.
Explanation:
1. A (Labor will likely be quick and easy, especially since this is your first pregnancy): This statement is incorrect because the duration and ease of labor are not solely determined by the patient's parity (number of pregnancies). Each labor is unique and may vary in length and intensity regardless of previous pregnancies.
2. C (You will probably need a cesarean section since you are at full term): This statement is incorrect as the majority of pregnant women deliver vaginally at full term. Cesarean section is not a predetermined outcome solely based on gestational age.
3. D (You may not feel any pain during labor because of modern pain relief options): This statement is incorrect because pain
A pregnant patient is at 24 weeks gestation and reports pain in her lower abdomen and back. What is the nurse's first priority action?
- A. Administer pain medication and encourage rest.
- B. Assess the patient for signs of preterm labor, including regular contractions.
- C. Instruct the patient to perform relaxation techniques to alleviate pain.
- D. Encourage the patient to exercise and walk around to relieve discomfort.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdomen and back pain could be indicative of preterm labor. Therefore, the nurse's first priority should be to assess the patient for signs of preterm labor, such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. This is crucial to determine if the patient and the fetus are in any immediate danger. Administering pain medication (choice A), instructing relaxation techniques (choice C), or encouraging exercise (choice D) are not appropriate initial actions as they do not address the potential serious issue of preterm labor.