Nokea
A nurse is preparing to administer a postpartum tetanus shot. What is the most important action before administering the shot?
- A. verify the person's immunization status
- B. assess the person's blood pressure
- C. assess for uterine atony
- D. prepare for a cesarean section
Correct Answer: C
Rationale: Rationale:
C is correct because assessing for uterine atony is crucial before administering a postpartum tetanus shot to ensure no postpartum hemorrhage risk. Uterine atony can lead to excessive bleeding, which can be exacerbated by the tetanus shot.
Summary:
A - Verifying immunization status is important but not the most immediate action.
B - Assessing blood pressure is important but not directly related to the risk of postpartum hemorrhage.
D - Preparing for a cesarean section is not necessary for administering a postpartum tetanus shot.
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A 38-week pregnant patient in active labor is experiencing frequent and painful contractions. What is the most appropriate action for the nurse?
- A. Administer narcotic analgesics for pain relief
- B. Provide emotional support and reassurance
- C. Assess the fetal heart rate and contraction patterns
- D. Prepare for delivery
Correct Answer: D
Rationale: The correct answer is D: Prepare for delivery. At 38 weeks of gestation and in active labor, the most appropriate action is to prepare for delivery as the patient is likely to be close to giving birth. This involves ensuring that all necessary equipment and supplies are ready, notifying the healthcare team, and positioning the patient for delivery. Administering narcotic analgesics (choice A) may not be ideal at this stage as the priority is the imminent delivery. While emotional support and reassurance (choice B) are important, they should be provided alongside preparing for delivery. Assessing the fetal heart rate and contraction patterns (choice C) is crucial but should be done concurrently with preparing for delivery to ensure the safety of both the mother and baby.
A nurse is caring for a patient in labor who is receiving oxytocin for induction. Which of the following is a priority assessment for the nurse?
- A. Fetal heart rate monitoring
- B. Fluid intake and output
- C. Uterine tone assessment
- D. Maternal blood pressure monitoring
Correct Answer: A
Rationale: The correct answer is A: Fetal heart rate monitoring. This is a priority assessment because oxytocin can cause uterine hyperstimulation, leading to fetal distress. Monitoring the fetal heart rate allows early detection of any signs of fetal compromise. Choices B, C, and D are important assessments but not the priority in this situation. Monitoring fluid intake and output, uterine tone, and maternal blood pressure are also crucial but do not directly assess fetal well-being, which is the primary concern during labor induction with oxytocin.
A client who was seen in the prenatal clinic at 20 weeks’ gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks’ gestation?
- A. 129 to 130 lb.
- B. 131 to 132 lb.
- C. 133 to 134 lb.
- D. 135 to 136 lb.
Correct Answer: C
Rationale: A weight gain of 1 lb per week is expected during the second and third trimesters. Therefore, the client should gain approximately 4 lb between 20 and 24 weeks.
A patient in labor is undergoing an epidural block and is given intravenous fluid. What is the purpose of this?
- A. To treat hypotension that results from hemorrhage
- B. To increase urine output
- C. To treat insensible fluid losses
- D. To treat hypotension that results from sympathetic blockade
Correct Answer: D
Rationale: The correct answer is D: To treat hypotension that results from sympathetic blockade. When an epidural block is administered during labor, sympathetic blockade can lead to a drop in blood pressure. By providing intravenous fluid, the goal is to increase preload and maintain blood pressure to counteract the hypotension caused by sympathetic blockade.
A: Treating hypotension from hemorrhage is not the primary purpose in this scenario.
B: Increasing urine output is not the main goal of giving intravenous fluid during an epidural block.
C: Treating insensible fluid losses is not the immediate concern when a patient is experiencing hypotension from sympathetic blockade.
What is the most common indication for performing an episiotomy?
- A. to prevent severe perineal tears
- B. to allow the birth to occur more quickly
- C. to relieve the risk of shoulder dystocia
- D. to control excessive vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: to control excessive vaginal bleeding. Episiotomy is primarily performed to manage and control postpartum hemorrhage by facilitating better visualization and access for suturing any bleeding vessels. It is not routinely done for preventing severe tears, expediting birth, or addressing shoulder dystocia, as there are alternative interventions for these situations. Episiotomy should be carefully considered and performed only when necessary to avoid unnecessary complications and promote better outcomes.