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A patient in labor is receiving Pitocin to augment contractions. The fetal heart rate shows late decelerations. What is the most appropriate intervention?
- A. Stop the Pitocin infusion
- B. Administer oxygen to the mother
- C. Change the patient's position
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because it addresses the potential causes of late decelerations comprehensively. Stopping Pitocin helps to eliminate uteroplacental insufficiency, administering oxygen improves fetal oxygenation, and changing the patient's position can alleviate pressure on the umbilical cord. Each intervention targets a different aspect contributing to late decelerations, making it crucial to implement all of them to optimize fetal well-being.
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The nurse is caring for a pregnant patient who is 30 weeks gestation and reports feeling faint and lightheaded. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to lie on her back to improve circulation.
- B. Encourage the patient to take deep breaths and sit down immediately.
- C. Instruct the patient to stand up slowly and rest for 10 minutes.
- D. Ask the patient to eat something sweet to raise her blood sugar.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to take deep breaths and sit down immediately. This action is appropriate because the patient is experiencing symptoms of hypotension, which can lead to decreased blood flow to the brain causing faintness and lightheadedness. By encouraging the patient to take deep breaths and sit down immediately, the nurse is helping to increase oxygen intake and improve circulation, which can alleviate the symptoms.
Explanation for why the other choices are incorrect:
A: Instructing the patient to lie on her back can actually worsen symptoms as it can lead to a decrease in blood flow to the brain.
C: Instructing the patient to stand up slowly is not appropriate as the patient is already feeling faint and lightheaded. This can increase the risk of falling and injury.
D: Asking the patient to eat something sweet may not address the underlying cause of the symptoms, which is likely related to hypotension. It is important to address the immediate
A pregnant patient is 26 weeks gestation and reports difficulty breathing when lying flat. What should the nurse recommend?
- A. Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm.
- B. Recommend sleeping in a fully reclined position to prevent shortness of breath.
- C. Administer oxygen as prescribed to ensure proper oxygenation.
- D. Instruct the patient to lie flat on her back and use a pillow for support.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm. At 26 weeks gestation, the uterus can compress the inferior vena cava when lying flat on the back, leading to decreased blood return to the heart and reduced cardiac output, causing difficulty breathing. Sleeping on the left side helps improve circulation by reducing pressure on the vena cava, enhancing blood flow and oxygenation to the fetus and mother.
Incorrect options:
B: Recommending sleeping in a fully reclined position may not alleviate the compression on the vena cava and could potentially worsen the patient's symptoms.
C: Administering oxygen may help with oxygenation but does not address the underlying issue of vena cava compression due to the growing uterus.
D: Instructing the patient to lie flat on her back can exacerbate the issue by further compressing the vena cava, worsening breathing difficulties.
What is the priority nursing action when a postpartum person experiences a boggy uterus after delivery?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. administer an analgesic
- D. administer pain medication
Correct Answer: B
Rationale: The correct answer is B: administer a uterotonic medication. This is the priority nursing action because a boggy uterus indicates uterine atony, which can lead to postpartum hemorrhage. Uterotonic medications help the uterus contract and reduce bleeding. Performing fundal massage (A) can be done after administering the medication to aid in uterine contraction. Administering an analgesic (C) or pain medication (D) is not the priority as the main concern is preventing excessive bleeding.
A pregnant patient at 26 weeks gestation reports dizziness and faintness when standing. Which intervention should the nurse prioritize?
- A. Encourage the patient to drink plenty of fluids and avoid standing for long periods.
- B. Instruct the patient to rise quickly from a seated position.
- C. Encourage the patient to lie flat on her back and rest.
- D. Advise the patient to take iron supplements to prevent dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink plenty of fluids and avoid standing for long periods. This intervention addresses the symptoms of dizziness and faintness by preventing dehydration and orthostatic hypotension common during pregnancy. Fluid intake maintains blood volume, reducing the risk of hypotension. Avoiding prolonged standing helps prevent blood pooling in the lower extremities. Choices B and C could exacerbate symptoms by causing sudden changes in blood pressure. Choice D is incorrect as iron supplements do not directly address the immediate issue of dizziness and faintness related to dehydration and orthostatic hypotension during pregnancy.
A pregnant patient is at 24 weeks gestation and reports pain in her lower abdomen and back. What is the nurse's first priority action?
- A. Administer pain medication and encourage rest.
- B. Assess the patient for signs of preterm labor, including regular contractions.
- C. Instruct the patient to perform relaxation techniques to alleviate pain.
- D. Encourage the patient to exercise and walk around to relieve discomfort.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdomen and back pain could be indicative of preterm labor. Therefore, the nurse's first priority should be to assess the patient for signs of preterm labor, such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. This is crucial to determine if the patient and the fetus are in any immediate danger. Administering pain medication (choice A), instructing relaxation techniques (choice C), or encouraging exercise (choice D) are not appropriate initial actions as they do not address the potential serious issue of preterm labor.