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A patient who has been in labor for several hours is now fully dilated and ready to push. What is the first action the nurse should take?
- A. Encourage the patient to push with each contraction
- B. Prepare the delivery room for delivery
- C. Assess the fetal heart rate
- D. Administer pain relief
Correct Answer: C
Rationale: The correct answer is C: Assess the fetal heart rate. This is important to ensure the baby's well-being during the pushing phase. By monitoring the fetal heart rate, the nurse can detect any signs of distress or complications, allowing for prompt intervention if needed. Encouraging the patient to push (A) is appropriate once the fetal well-being is confirmed. While preparing the delivery room (B) is important, it is not the immediate priority. Administering pain relief (D) can be considered after assessing the fetal heart rate and ensuring the baby's safety.
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A nurse is assessing a laboring person's progress. What is the most reliable indicator that the laboring person is in the active phase of labor?
- A. Progressive cervical dilation
- B. Frequent, regular contractions
- C. Fetal descent
- D. Effacement of the cervix
Correct Answer: A
Rationale: The correct answer is A: Progressive cervical dilation. This is the most reliable indicator of the active phase of labor because it directly reflects the opening of the cervix, indicating that labor is advancing. Cervical dilation is a key aspect of labor progress and is used to determine the stage of labor. Frequent, regular contractions (choice B) are important but can occur in early labor as well. Fetal descent (choice C) is an important aspect but may happen in conjunction with cervical dilation. Effacement of the cervix (choice D) is also important but does not solely indicate the active phase of labor.
A pregnant patient at 32 weeks gestation reports persistent nausea and vomiting. What is the nurse's priority action?
- A. Instruct the patient to take over-the-counter anti-nausea medication.
- B. Monitor the patient's hydration status and assess for signs of dehydration.
- C. Encourage the patient to eat large meals more frequently to prevent nausea.
- D. Recommend the patient avoid drinking fluids to prevent further vomiting.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's hydration status and assess for signs of dehydration. This is the priority action because nausea and vomiting during pregnancy can lead to dehydration, which can have serious consequences for both the mother and the baby. By monitoring the patient's hydration status and assessing for signs of dehydration, the nurse can ensure early intervention if dehydration occurs.
Incorrect choices:
A: Instruct the patient to take over-the-counter anti-nausea medication - This is not the priority as dehydration needs to be addressed first.
C: Encourage the patient to eat large meals more frequently to prevent nausea - This may exacerbate the nausea and vomiting, leading to further dehydration.
D: Recommend the patient avoid drinking fluids to prevent further vomiting - Dehydration can worsen if the patient avoids fluids.
The nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with a urinary tract infection (UTI). Which of the following interventions should the nurse prioritize?
- A. Administer antibiotics as prescribed.
- B. Encourage the patient to drink cranberry juice.
- C. Provide education about the signs of preterm labor.
- D. Schedule a follow-up ultrasound to assess fetal health.
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics as prescribed. The priority is to treat the UTI to prevent potential harm to the patient and fetus. Antibiotics are necessary to eliminate the infection and reduce the risk of complications. Encouraging cranberry juice (B) may be beneficial for prevention but is not sufficient to treat an existing UTI. Providing education about preterm labor signs (C) is important but addressing the infection is the immediate concern. Scheduling a follow-up ultrasound (D) may be necessary later but does not address the urgent need to treat the UTI.
A nurse is caring for a laboring person who is in the first stage of labor. What is the priority assessment to perform during this stage?
- A. monitor vital signs
- B. perform a vaginal exam
- C. perform a cervical check
- D. monitor the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: monitor vital signs. During the first stage of labor, it is crucial to monitor the laboring person's vital signs to assess for any signs of distress or complications. This includes monitoring blood pressure, pulse rate, respiratory rate, and temperature. By closely monitoring vital signs, the nurse can identify any potential issues early on and take appropriate actions to ensure the safety and well-being of both the laboring person and the baby. Performing a vaginal exam (B) or cervical check (C) may be necessary later in labor but is not the priority assessment during the first stage. Monitoring the fetal heart rate (D) is also important but not the priority over monitoring the laboring person's vital signs.
A 40-year-old primiparous woman who is 38 weeks pregnant has been on the labor unit for an hour when she starts to complain of feeling dizzy, light-headed, and nauseous. Her blood pressure is 90/60. What should be the first response of the nurse?
- A. Give the patient a bolus of intravenous fluid.
- B. Turn the patient to her left side.
- C. Call the obstetrician or nurse midwife.
- D. Give the patient an antiemetic medication for the nausea.
Correct Answer: B
Rationale: The correct answer is B: Turn the patient to her left side.
Rationale:
1. The patient's symptoms of dizziness, light-headedness, and low blood pressure (90/60) suggest hypotension, which could be due to supine hypotensive syndrome in pregnancy.
2. Turning the patient to her left side can help alleviate pressure on the vena cava, improving blood flow back to the heart and subsequently increasing blood pressure.
3. This immediate action can help prevent further complications such as decreased placental perfusion and fetal distress.
Summary:
- Choice A (Give the patient a bolus of intravenous fluid): While IV fluids may be needed, the priority is to address the underlying cause of hypotension first.
- Choice C (Call the obstetrician or nurse midwife): While it is important to involve the healthcare provider, immediate action to address the hypotension is crucial.
- Choice D (Give the patient an antiemetic medication for