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A nurse is caring for a postpartum person who is at risk for uterine atony. What is the priority intervention to prevent uterine atony?
- A. administer uterotonic medication
- B. administer an analgesic
- C. perform uterine massage
- D. administer IV fluids
Correct Answer: B
Rationale: The correct answer is B: administer an analgesic. This is the priority intervention because pain management helps the person relax, which reduces stress on the uterus and promotes effective contraction to prevent uterine atony. Administering uterotonic medication (choice A) may help contract the uterus but addressing pain first is crucial. Performing uterine massage (choice C) can assist in contracting the uterus but is not the priority intervention. Administering IV fluids (choice D) is important for hydration but does not directly address preventing uterine atony.
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Which of the following is a risk factor for developing a cesarean section?
- A. Fetal malpresentation
- B. Spontaneous labor
- C. Low maternal age
- D. No previous pregnancies
Correct Answer: A
Rationale: The correct answer is A: Fetal malpresentation. This is a risk factor for cesarean section because the baby's position can impact the ability to deliver vaginally. If the baby is in a breech or transverse position, a cesarean section may be necessary to ensure a safe delivery.
Choice B, spontaneous labor, is not a risk factor for cesarean section as it is a natural part of childbirth. Choice C, low maternal age, is also not a risk factor as age alone does not determine the need for a cesarean section. Choice D, no previous pregnancies, is not a risk factor as it does not directly impact the likelihood of needing a cesarean section.
A nurse is caring for a patient in labor who is experiencing intense pain. Which of the following would be the most appropriate intervention to manage pain during labor?
- A. Encourage the patient to practice deep breathing and relaxation techniques.
- B. Administer intravenous fluids to reduce pain sensation.
- C. Provide a sedative to help the patient rest between contractions.
- D. Suggest an epidural to block pain completely.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to practice deep breathing and relaxation techniques. This is the most appropriate intervention to manage pain during labor because deep breathing and relaxation techniques can help the patient to cope with the pain, reduce stress, and promote a sense of control. These techniques are safe, non-invasive, and can be effective in managing labor pain without the need for medication or invasive procedures.
Summary:
- Choice B (Administer intravenous fluids): Intravenous fluids do not directly reduce pain sensation and are not a primary intervention for managing labor pain.
- Choice C (Provide a sedative): Sedatives may affect the baby and can interfere with the progress of labor. They do not address the root cause of pain during labor.
- Choice D (Suggest an epidural): While epidurals can provide effective pain relief, they are not always necessary or desired by all patients. Encouraging non-pharmacological methods first is often preferred.
A nurse is caring for a postpartum person who is at risk for infection. What is the most important nursing action to reduce the risk of infection?
- A. provide perineal care and hygiene
- B. ensure proper hand hygiene
- C. offer antibiotics as needed
- D. ensure proper infection control practices
Correct Answer: C
Rationale: The correct answer is C: offer antibiotics as needed. In postpartum individuals at high risk for infection, antibiotics may be necessary to prevent or treat infections. Antibiotics target specific pathogens, reducing the risk of infection. Proper hand hygiene (B) and infection control practices (D) are important but do not directly address the underlying risk of infection. Providing perineal care and hygiene (A) is essential for overall hygiene but may not be sufficient in preventing infections in high-risk individuals. Antibiotics, when prescribed judiciously and appropriately, can be crucial in reducing the risk of infection and promoting recovery.
The nurse’s role in diagnostic testing is to provide which of the following?
- A. Advice to the couple
- B. Information about the tests
- C. Reassurance about fetal safety
- D. Assistance with decision making
Correct Answer: B
Rationale: The nurse's role is to provide all necessary information regarding a procedure to enable the couple to make an informed decision.
A nurse is caring for a laboring person who is experiencing irregular contractions. What is the priority intervention to address this issue?
- A. Administer tocolytics
- B. Administer analgesics
- C. Monitor fetal heart rate
- D. Increase oxytocin infusion
Correct Answer: A
Rationale: The correct answer is A: Administer tocolytics. Tocolytics help to inhibit uterine contractions and can be used to address irregular contractions during labor. This intervention helps to prevent preterm labor and promote fetal well-being. Administering analgesics (choice B) may help with pain management but does not address the underlying issue of irregular contractions. Monitoring fetal heart rate (choice C) is important but does not directly address the irregular contractions. Increasing oxytocin infusion (choice D) would worsen the situation by further stimulating contractions. Therefore, administering tocolytics is the priority intervention to address irregular contractions during labor.