Nokea
A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences
- A. increased fetal movement.
- B. irregular contractions for 1 hour.
- C. a trickle of fluid from the vagin
- D. thick pink or dark red vaginal mucus.
Correct Answer: C
Rationale: The correct answer is C because a trickle of fluid from the vagina at 40 weeks' gestation could indicate the rupture of membranes, which is a sign of impending labor. This warrants immediate evaluation to assess the status of the amniotic sac and the need for monitoring or intervention.
Explanation for other choices:
A: Increased fetal movement is a normal sign of fetal well-being and not a reason for immediate evaluation.
B: Irregular contractions for 1 hour may not necessarily indicate active labor, so immediate evaluation is not needed.
D: Thick pink or dark red vaginal mucus may indicate bloody show, which can be a sign of labor starting, but it is not as urgent as a potential rupture of membranes.
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The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?
- A. 18-gauge
- B. 20-gauge
- C. 22-gauge
- D. 24-gauge
Correct Answer: B
Rationale: The correct answer is B: 20-gauge. During active labor, a larger IV cannula is recommended to accommodate rapid fluid administration and potential blood loss. A 20-gauge cannula provides a good balance between flow rate and patient comfort. An 18-gauge cannula (choice A) may be too large and cause discomfort, while 22-gauge (choice C) and 24-gauge (choice D) may not allow for adequate fluid administration in a timely manner.
Following an external cephalic version, which assessment finding indicates a complication?
- A. Onset of irregular contractions
- B. Maternal blood pressure of 110/70 mm Hg
- C. Deceleration of FHR to 88 bpm
- D. Maternal pulse rate of 100 bpm
Correct Answer: C
Rationale: The correct answer is C: Deceleration of FHR to 88 bpm. This finding indicates fetal distress, a complication post external cephalic version. Deceleration of FHR suggests reduced oxygenation to the fetus. A: Onset of irregular contractions is a common post-procedure finding and not necessarily indicative of a complication. B: Maternal blood pressure of 110/70 mm Hg is within normal range and not directly related to a complication. D: Maternal pulse rate of 100 bpm is slightly elevated but not a specific indicator of a complication post external cephalic version.
The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
- A. To determine the status of the membranes
- B. To determine cervical dilation and effacement
- C. To determine the best location to assess the fetal heart rate
- D. To determine whether the fetus is in the posterior position
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
What are the side effects of spinal anesthesia? Select one that doesn't apply.
- A. hypotension
- B. respiratory depression
- C. renal damage
- D. infection
Correct Answer: C
Rationale: The correct answer is C: renal damage. Spinal anesthesia affects the nervous system, not the kidneys. Hypotension and respiratory depression are common side effects due to vasodilation and decreased respiratory drive. Infection can occur due to the invasive nature of the procedure. Renal damage is not a known side effect of spinal anesthesia as it does not directly affect kidney function.
Which nursing action is most appropriate for a laboring patient experiencing severe back pain due to a posterior fetal position?
- A. Offer narcotic analgesics for pain relief.
- B. Encourage frequent position changes.
- C. Provide continuous fetal monitoring.
- D. Prepare the patient for an immediate cesarean delivery.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent position changes. This is because changing positions can help alleviate pressure on the back and potentially help the baby rotate into a more favorable position for delivery. It is a non-invasive and supportive approach to managing back pain during labor. Offering narcotic analgesics (choice A) may provide temporary relief but does not address the underlying issue. Continuous fetal monitoring (choice C) is important but not the most immediate intervention for back pain. Immediately preparing for a cesarean delivery (choice D) is not warranted unless there are other concerning factors beyond back pain.