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A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.
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During the postpartum period, a nurse is caring for a birthing person who is receiving uterotonic medications. The nurse's assessment reveals a boggy and enlarged uterus. What is the nurse's immediate action?
- A. Document the findings as normal.
- B. Continue to administer the uterotonic medication.
- C. Perform fundal massage to promote uterine firmness.
- D. Administer an analgesic for the birthing person's pain.
Correct Answer: C
Rationale: The correct immediate action is C: Perform fundal massage to promote uterine firmness. Fundal massage helps prevent postpartum hemorrhage by promoting uterine contraction and firmness. A: Documenting the findings as normal is incorrect as a boggy and enlarged uterus is not a normal finding postpartum. B: Continuing to administer uterotonic medication without addressing the boggy uterus can lead to ineffective contraction. D: Administering an analgesic for pain does not address the underlying issue of uterine atony.
Which foods equal 1 ounce serving size from the grain group? Select all that apply.
- A. 1 bagel
- B. 1 slice of bread
- C. 1 cup cooked pasta
- D. 1 tortilla
Correct Answer: B
Rationale: 1 slice of bread and 1 tortilla each equal 1 ounce serving size. A bagel and 1 cup cooked pasta exceed this size.
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head crowns?
- A. apply gentle downward pressure
- B. assist with shoulder delivery
- C. assist with perineal massage
- D. administer pain relief
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of perineal tearing and ensuring a controlled birth. Applying too much pressure can cause trauma to the mother and baby. Incorrect choices: B is premature, as shoulder delivery should only be done after the head and shoulders are delivered. C is not the most important action at crowning. D is not necessary at this specific stage of delivery.
A laboring person on oxytocin for induction of labor should have continuous monitoring of the fetal heart rate. How often should the nurse assess the fetal heart rate?
- A. every 30 minutes
- B. every 15 minutes
- C. every 5 minutes
- D. every 1 hour
Correct Answer: B
Rationale: The correct answer is B: every 15 minutes. Continuous monitoring of the fetal heart rate is crucial during labor induction with oxytocin to promptly detect any signs of fetal distress. Assessing the fetal heart rate every 15 minutes allows for frequent monitoring to ensure the baby's well-being and timely intervention if needed. Assessing every 30 minutes (choice A) may not provide adequate monitoring frequency, every 5 minutes (choice C) is too frequent and may not be practical, and every 1 hour (choice D) is too long of an interval between assessments, potentially missing important changes in fetal status.
Which is an expected characteristic of amniotic fluid?
- A. Deep yellow color
- B. Clear, with small white particles
- C. Nitrazine test: acidic result
- D. Absence of ferning
Correct Answer: B
Rationale: The correct answer is B: Clear, with small white particles. Amniotic fluid is typically clear with small white particles, representing vernix caseosa. Vernix caseosa is a white, cheese-like substance that covers the skin of the fetus. It helps protect the skin and regulate body temperature. The presence of vernix particles in amniotic fluid is a normal and expected characteristic.
Incorrect choices:
A: Deep yellow color - Amniotic fluid is usually clear or slightly straw-colored. A deep yellow color may indicate the presence of meconium, which suggests fetal distress.
C: Nitrazine test: acidic result - Amniotic fluid is normally alkaline, not acidic. An acidic result may indicate infection.
D: Absence of ferning - Ferning is a characteristic pattern seen under a microscope in dried cervical mucus, not amniotic fluid. Absence of ferning in amniotic fluid is not a relevant characteristic.