Nokea
A nurse is preparing a laboring person for an epidural. What is the priority nursing intervention before the procedure?
- A. ensure informed consent
- B. check for allergies to anesthesia
- C. assess for fetal movement
- D. administer pain relief
Correct Answer: C
Rationale: The correct answer is C: assess for fetal movement. This is the priority intervention before an epidural to ensure the safety and well-being of the fetus. Assessing for fetal movement helps determine the fetal well-being and any potential distress that may require immediate intervention. Ensuring informed consent (A) is important but assessing fetal well-being takes precedence. Checking for allergies to anesthesia (B) is important but not the priority before assessing fetal movement. Administering pain relief (D) can be done after assessing fetal movement to ensure the safety of both the laboring person and the fetus.
You may also like to solve these questions
A pregnant woman in her second trimester asks the nurse about taking herbal supplements to alleviate nausea. Which of the following is the nurse's best response?
- A. It is safe to take any herbal supplement during pregnancy.
- B. Some herbal supplements may cause harm to your pregnancy, and it's best to consult your doctor.
- C. Only certain over-the-counter medications are safe, not herbal supplements.
- D. Herbal supplements are more effective than prescription medications for nausea.
Correct Answer: B
Rationale: The correct answer is B because herbal supplements can vary in safety during pregnancy. It is always recommended to consult a healthcare provider before taking any supplements, as some herbs may potentially harm the pregnancy or interact with other medications. Answer A is incorrect as not all herbal supplements are safe during pregnancy. Answer C is incorrect as some herbal supplements may be safe if recommended by a healthcare provider. Answer D is incorrect as prescription medications are often more rigorously tested and regulated for safety during pregnancy compared to herbal supplements.
A pregnant patient is 36 weeks gestation and reports increased vaginal discharge. What is the nurse's priority action?
- A. Assess the nature of the discharge for signs of infection.
- B. Instruct the patient to monitor the discharge at home.
- C. Recommend the patient use panty liners to manage the discharge.
- D. Provide education about normal pregnancy changes, including discharge.
Correct Answer: A
Rationale: The correct answer is A: Assess the nature of the discharge for signs of infection. At 36 weeks gestation, increased vaginal discharge could be a sign of infection, such as bacterial vaginosis or yeast infection, which can lead to preterm labor. The nurse's priority is to assess for infection to prevent any potential harm to the mother and baby. By assessing the nature of the discharge, the nurse can determine if further evaluation or treatment is needed.
Choice B is incorrect because instructing the patient to monitor the discharge at home does not address the potential seriousness of the situation. Choice C is incorrect as using panty liners only manages the symptom without addressing the underlying cause. Choice D is incorrect because providing education about normal pregnancy changes does not address the immediate need to rule out infection in this scenario.
A nurse is preparing a laboring person for a cesarean birth. What is the most important intervention before the procedure?
- A. administer preoperative medication
- B. monitor vital signs
- C. ensure proper incision care
- D. perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A because administering preoperative medication is crucial to ensure the patient's comfort and safety during the cesarean birth. Preoperative medications help reduce anxiety, prevent infection, and manage pain. Monitoring vital signs (choice B) is important but not the most critical intervention before the procedure. Ensuring proper incision care (choice C) is postoperative, not preoperative. Performing a vaginal exam (choice D) is unnecessary and potentially harmful before a cesarean birth.
What is the most common cause of shoulder dystocia during delivery?
- A. fetal macrosomia
- B. maternal obesity
- C. maternal diabetes
- D. advanced maternal age
Correct Answer: A
Rationale: The correct answer is A: fetal macrosomia. Fetal macrosomia, defined as a birth weight above 4 kg, is the most common cause of shoulder dystocia during delivery. This occurs when the baby's shoulders get stuck behind the mother's pelvic bone, leading to complications. Macrosomia is more likely in pregnancies with gestational diabetes, maternal obesity, and advanced maternal age, but the primary risk factor for shoulder dystocia is fetal macrosomia due to the large size of the baby. Maternal obesity, diabetes, and advanced age are secondary risk factors that can contribute to the likelihood of shoulder dystocia but are not the primary cause.
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.