Nokea
A patient in labor begins to experience significant vaginal bleeding. What is the first step the nurse should take?
- A. Administer oxygen to the patient
- B. Check for a cord prolapse
- C. Perform a vaginal examination
- D. Perform a vaginal examination
Correct Answer: B
Rationale: The correct answer is B: Check for a cord prolapse. This is the first step because cord prolapse is a critical emergency that can lead to fetal compromise. By checking for cord prolapse, the nurse can quickly assess the situation and take appropriate actions to relieve pressure on the cord. Administering oxygen (choice A) may be necessary later but not the first step. Performing a vaginal examination (choices C and D) can exacerbate the situation by pushing the cord further into the birth canal.
You may also like to solve these questions
A pregnant patient at 36 weeks gestation reports feeling short of breath when lying flat. What is the nurse's priority action?
- A. Administer oxygen and prepare the patient for delivery.
- B. Encourage the patient to sit up and rest in a more upright position.
- C. Ask the patient to perform deep breathing exercises to improve oxygen flow.
- D. Instruct the patient to take shallow breaths and avoid exertion.
Correct Answer: B
Rationale: The correct answer is B because positioning the pregnant patient in a more upright position can help alleviate the shortness of breath by allowing the diaphragm to move more freely, reducing pressure on the lungs, and improving oxygenation. This action promotes optimal oxygen flow and comfort for the patient.
A: Administering oxygen and preparing for delivery may be necessary in some cases but does not address the immediate need to alleviate shortness of breath caused by the supine position.
C: Deep breathing exercises may not be effective in relieving shortness of breath caused by the supine position and may even exacerbate the discomfort.
D: Instructing the patient to take shallow breaths and avoid exertion does not address the underlying cause of shortness of breath and may not provide adequate relief.
What is the purpose of the Leopold's maneuver in labor and delivery?
- A. to assess fetal presentation and position
- B. to assess fetal position and the location of the placenta
- C. to assess uterine tone and fetal heart rate
- D. to assess the fetal heart rate pattern
Correct Answer: A
Rationale: The purpose of Leopold's maneuver in labor and delivery is to assess fetal presentation and position. Step 1 evaluates the fundal grip to determine the fetal part. Step 2 assesses the sides of the abdomen to identify the fetal back. Step 3 determines the presenting part and position. Step 4 confirms the presenting part and its mobility. This systematic approach helps determine the position of the fetus in the uterus. Choices B, C, and D are incorrect as they do not align with the specific purpose of Leopold's maneuver, which is primarily focused on assessing fetal presentation and position.
In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
- A. every 5 minutes with contractions
- B. at least every 30 minutes
- C. every 5–15 minutes
- D. only when the physician orders assessment
Correct Answer: C
Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.
A patient in labor is requesting an epidural but has a history of a previous back surgery. What is the most important assessment before proceeding with the epidural?
- A. History of spinal surgery or deformity
- B. Fetal heart rate
- C. Perform a vaginal exam to assess for fetal position
- D. Administer Pitocin
Correct Answer: C
Rationale: The correct answer is C: Perform a vaginal exam to assess for fetal position. This is important because the position of the fetus can affect the safety and efficacy of administering an epidural in a patient with a history of back surgery. If the fetus is in a breech position or in any other position that could complicate the epidural placement, alternative pain management options may need to be considered.
A: History of spinal surgery or deformity is important but assessing the fetal position takes precedence in this scenario.
B: Fetal heart rate monitoring is essential during labor but not the most important assessment before proceeding with the epidural in this case.
D: Administering Pitocin is unrelated to the assessment needed before proceeding with the epidural.
A nurse is caring for a pregnant patient who is 8 weeks gestation. The patient is asking about the safety of taking over-the-counter cold medications. Which response is most appropriate?
- A. It is safe to take any over-the-counter medication during pregnancy.
- B. You should only take medications that are specifically labeled for pregnancy use.
- C. Cold medications are never safe to take during pregnancy.
- D. Only herbal remedies are safe for treating colds during pregnancy.
Correct Answer: B
Rationale: The correct answer is B because during pregnancy, it is essential to be cautious about medications. Choosing medications specifically labeled for pregnancy ensures safety for both the mother and the developing fetus. Choice A is incorrect because not all over-the-counter medications are safe during pregnancy. Choice C is incorrect as some cold medications are safe when used as directed. Choice D is incorrect as not all herbal remedies are proven safe for use during pregnancy. It is important to prioritize the well-being of both the mother and the baby by following healthcare provider recommendations and using medications approved for use during pregnancy.