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A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
- A. ensure the birthing person is in a sitting position
- B. check for allergies to anesthesia
- C. ensure informed consent is obtained
- D. administer IV fluids
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically.
Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.
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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 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.
A pregnant patient is at 34 weeks gestation and reports sudden sharp abdominal pain and difficulty breathing. What is the nurse's priority action?
- A. Encourage the patient to lie down and monitor the symptoms.
- B. Administer pain medication and schedule an ultrasound.
- C. Call the healthcare provider immediately and prepare for possible preterm labor.
- D. Assess the fetal heart rate and monitor for contractions.
Correct Answer: C
Rationale: The correct answer is C - Call the healthcare provider immediately and prepare for possible preterm labor. At 34 weeks gestation, sudden sharp abdominal pain and difficulty breathing could indicate a serious complication such as placental abruption or pulmonary embolism. Calling the healthcare provider ensures prompt assessment and appropriate intervention to prevent harm to the mother and baby. Encouraging the patient to lie down may delay necessary intervention. Administering pain medication before determining the cause of pain could mask important symptoms. Assessing the fetal heart rate and monitoring for contractions are important but secondary actions to calling the healthcare provider in this urgent situation.
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.
A pregnant patient reports nausea and vomiting and asks the nurse about ways to manage these symptoms. Which of the following suggestions should the nurse make?
- A. Eat large meals to avoid hunger and nausea.
- B. Take anti-nausea medication without consulting a provider.
- C. Avoid foods with strong smells and eat small, frequent meals.
- D. Lie down immediately after meals to prevent nausea.
Correct Answer: C
Rationale: The correct answer is C: Avoid foods with strong smells and eat small, frequent meals. This suggestion is appropriate as it helps manage nausea and vomiting in pregnancy. Avoiding strong smells can reduce triggers for nausea, and eating small, frequent meals helps maintain stable blood sugar levels. This approach prevents the stomach from becoming too full or too empty, which can trigger nausea.
A: Eating large meals can exacerbate nausea and vomiting due to increased stomach distention.
B: Taking anti-nausea medication without consulting a healthcare provider is not safe during pregnancy as it may harm the fetus.
D: Lying down immediately after meals can worsen symptoms by promoting reflux and indigestion.
In summary, Option C is the best choice as it addresses the symptoms of nausea and vomiting in pregnancy effectively.