Nokea
A woman in labor begins to experience uterine rupture. What is the most important intervention?
- A. Administer pain relief medication
- B. Prepare for an emergency cesarean section
- C. Administer oxygen to the mother
- D. Increase the IV fluid rate
Correct Answer: B
Rationale: The correct answer is B: Prepare for an emergency cesarean section. Uterine rupture during labor is a life-threatening emergency requiring immediate surgical intervention to prevent catastrophic outcomes for both the mother and the baby. A cesarean section is the most effective and timely intervention to address the uterine rupture and ensure the safety of both individuals. Administering pain relief medication (A) may be necessary but is not the most urgent intervention. Administering oxygen to the mother (C) can help with oxygenation, but it does not address the underlying issue of uterine rupture. Increasing IV fluid rate (D) may be helpful in some situations but is not the primary intervention needed to manage uterine rupture.
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During open glottis pushing, what is the laboring person instructed to do?
- A. hold their breath and push for 10 seconds during each contraction
- B. push spontaneously while exhaling during contractions
- C. exhale slowly during contractions without pushing
- D. perform deep breathing exercises between contractions
Correct Answer: B
Rationale: During open glottis pushing, the correct instruction is for the laboring person to push spontaneously while exhaling during contractions (Choice B). This technique helps prevent breath-holding, which can increase intra-abdominal pressure and reduce blood flow to the heart and baby. Exhaling while pushing allows for better oxygenation and reduces the risk of Valsalva maneuver-related complications. Holding their breath (Choice A) can increase the risk of fetal distress. Exhaling slowly without pushing (Choice C) is not effective in assisting with the pushing stage of labor. Deep breathing exercises between contractions (Choice D) are beneficial for relaxation but not the main focus during pushing.
A nurse is caring for a pregnant patient at 32 weeks gestation who is diagnosed with anemia. What is the nurse's priority teaching for this patient?
- A. You should take iron supplements with milk to improve absorption.
- B. You should take iron supplements with a vitamin C source, such as orange juice.
- C. You should avoid taking iron supplements during the second trimester.
- D. You should take iron supplements with calcium-rich foods to increase absorption.
Correct Answer: B
Rationale: The correct answer is B because vitamin C enhances iron absorption. Iron supplements should be taken with a vitamin C source, such as orange juice, to maximize absorption and effectiveness in treating anemia. Iron absorption is hindered by calcium-rich foods and milk, so options A and D are incorrect. Option C is also incorrect as iron supplementation is crucial during pregnancy to prevent and treat anemia.
The nurse is caring for a pregnant patient who is 22 weeks gestation and has a history of gestational hypertension. What should the nurse monitor most closely?
- A. Blood glucose levels to check for gestational diabetes
- B. Protein in the urine to assess for preeclampsia
- C. Fetal heart rate to check for signs of fetal distress
- D. Daily weight gain to assess for fluid retention
Correct Answer: B
Rationale: The correct answer is B: Protein in the urine to assess for preeclampsia. The nurse should closely monitor protein in the urine because the patient has a history of gestational hypertension, which puts her at risk for developing preeclampsia. Preeclampsia is characterized by high blood pressure and proteinuria. Monitoring protein in the urine helps detect early signs of preeclampsia, which can lead to serious complications for both the mother and the fetus if left untreated.
Blood glucose levels (A) are not the priority in this case, as the patient's history indicates a higher risk for preeclampsia. Fetal heart rate (C) and daily weight gain (D) are important aspects to monitor during pregnancy; however, in this scenario, the focus should be on detecting signs of preeclampsia due to the patient's history of gestational hypertension.
A nurse is caring for a laboring person who is experiencing late decelerations in fetal heart rate. What is the priority nursing intervention?
- A. place the person on their left side
- B. apply oxygen via mask
- C. administer pain medication
- D. perform a vaginal examination
Correct Answer: A
Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.
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