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A nurse is preparing a laboring person for an emergency cesarean birth. What is the most important nursing intervention prior to the procedure?
- A. administer a preoperative medication
- B. administer pain relief
- C. administer an epidural block
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: administer a preoperative medication. This is crucial prior to an emergency cesarean birth to ensure the person is adequately prepared for the procedure. Preoperative medications can help reduce anxiety, prevent complications such as aspiration during anesthesia induction, and promote smooth recovery post-surgery. Administering pain relief (B) and epidural block (C) may be important for comfort but are not the priority in this urgent situation. Administering IV fluids (D) is generally important in preparation for surgery, but administering preoperative medication takes precedence in this scenario to ensure the person's safety and well-being during the emergency cesarean birth.
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A woman in labor begins to experience severe lower abdominal pain and is found to have a ruptured uterus. What is the first intervention the nurse should perform?
- A. Administer intravenous fluids
- B. Prepare the patient for immediate surgery
- C. Perform a vaginal examination
- D. Administer pain relief medications
Correct Answer: B
Rationale: The correct answer is B: Prepare the patient for immediate surgery. In the case of a ruptured uterus, prompt surgical intervention is crucial to control bleeding, repair the uterus, and prevent further complications such as hemorrhage and infection. Performing surgery is the priority over other interventions like administering fluids, pain relief medications, or performing a vaginal examination, as these actions do not address the immediate life-threatening situation of uterine rupture. Administering IV fluids may be necessary during surgery, and pain relief can be addressed post-operatively. Vaginal examination is contraindicated in cases of suspected uterine rupture as it can exacerbate the bleeding and worsen the condition.
A nurse is caring for a pregnant patient who is 26 weeks gestation and reports feeling dizzy when standing. What should the nurse recommend to the patient?
- A. Stand up slowly and make sure to drink plenty of fluids.
- B. Sit down immediately and rest for 10 minutes.
- C. Lie flat on your back to increase blood flow to the brain.
- D. Take deep breaths and elevate your legs while sitting.
Correct Answer: A
Rationale: The correct answer is A: Stand up slowly and make sure to drink plenty of fluids. When a pregnant patient feels dizzy when standing, it is likely due to postural hypotension. Standing up slowly helps prevent a sudden drop in blood pressure, which can cause dizziness. Drinking plenty of fluids helps maintain adequate blood volume and prevents dehydration, another common cause of dizziness during pregnancy. Sitting down immediately (B) may help temporarily but does not address the underlying issue. Lying flat on the back (C) can worsen symptoms by putting pressure on the vena cava, reducing blood flow to the brain. Taking deep breaths and elevating legs (D) may not be effective in addressing postural hypotension.
A woman in labor begins to experience uterine rupture. What is the most important intervention?
- A. Administer pain relief medication
- B. Prepare for an emergency cesarean section
- C. Administer oxygen to the mother
- D. Increase the IV fluid rate
Correct Answer: B
Rationale: The correct answer is B: Prepare for an emergency cesarean section. Uterine rupture during labor is a life-threatening emergency requiring immediate surgical intervention to prevent catastrophic outcomes for both the mother and the baby. A cesarean section is the most effective and timely intervention to address the uterine rupture and ensure the safety of both individuals. Administering pain relief medication (A) may be necessary but is not the most urgent intervention. Administering oxygen to the mother (C) can help with oxygenation, but it does not address the underlying issue of uterine rupture. Increasing IV fluid rate (D) may be helpful in some situations but is not the primary intervention needed to manage uterine rupture.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most important action to promote fetal descent?
- A. coach the person through controlled pushing
- B. increase maternal hydration
- C. provide comfort measures
- D. apply gentle pressure to the abdomen
Correct Answer: A
Rationale: The correct answer is A: coach the person through controlled pushing. This is the most important action to promote fetal descent during the second stage of labor because pushing helps the baby move through the birth canal. Controlled pushing helps prevent exhaustion and reduces the risk of maternal injury. Increasing maternal hydration (choice B) is important for overall well-being but does not directly promote fetal descent. Comfort measures (choice C) are important for pain management but do not directly aid in fetal descent. Applying gentle pressure to the abdomen (choice D) is not recommended as it can interfere with the natural process of labor.
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.