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A woman in labor has a history of previous cesarean section. What is the most important factor to monitor for during this labor?
- A. Uterine rupture
- B. Maternal hypotension
- C. Fetal malpresentation
- D. Prolonged labor
Correct Answer: A
Rationale: The correct answer is A: Uterine rupture. The most important factor to monitor in a woman with a history of previous cesarean section is the risk of uterine rupture during labor. Uterine rupture is a serious complication that can lead to life-threatening hemorrhage for both the mother and the baby. Monitoring for signs such as sudden onset of severe abdominal pain, abnormal fetal heart rate patterns, and cessation of contractions is crucial. Maternal hypotension (Choice B) is important but not as critical as uterine rupture. Fetal malpresentation (Choice C) and prolonged labor (Choice D) are important factors to monitor but do not pose the same level of immediate risk as uterine rupture in this situation.
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What factor should the nurse consider when counseling a Chinese immigrant?
- A. Many Chinese eat little protein
- B. Many Chinese believe in eating cold foods
- C. Many Chinese are prone to anemia
- D. Many Chinese believe strawberries cause birth defects
Correct Answer: D
Rationale: Cultural beliefs, such as the idea that strawberries might cause birth defects, should be considered to provide culturally sensitive care.
A 24-year-old patient is in labor and requests pain relief. What is the most appropriate intervention for a patient who is in the active phase of labor?
- A. Administer an epidural block
- B. Provide non-pharmacological pain relief methods
- C. Administer narcotic analgesics
- D. Encourage the patient to push with each contraction
Correct Answer: A
Rationale: The correct answer is A: Administer an epidural block. In the active phase of labor, the pain is typically intense and continuous. Administering an epidural block can provide effective pain relief by blocking nerve signals, allowing the patient to rest and conserve energy for the pushing phase. It does not affect the ability to push and can improve maternal satisfaction. Non-pharmacological methods (B) may not provide sufficient relief at this stage. Narcotic analgesics (C) can cross the placenta and affect the baby's respiratory system. Encouraging the patient to push (D) is appropriate during the second stage of labor, not the active phase.
A laboring person is requesting an epidural for pain relief. What is the most important nursing action before the procedure?
- A. administer an epidural bolus
- B. check for any contraindications
- C. perform a vaginal exam
- D. ensure continuous fetal monitoring
Correct Answer: B
Rationale: The correct answer is B: check for any contraindications. Before administering an epidural, it is crucial to assess for contraindications such as low platelet count, infection at the insertion site, or severe hypotension as these may increase the risk of complications. Administering an epidural bolus (A) without checking for contraindications can be dangerous. Performing a vaginal exam (C) is not necessary before an epidural and could increase the risk of infection. Ensuring continuous fetal monitoring (D) is important during labor but is not the most critical action before administering an epidural.
The nurse is caring for a 15-year-old female who is pregnant with her first child. In her previous prenatal visit, the patient tested negative for chlamydia, syphilis, gonorrhea, and HIV. Based on the information provided, which condition is the patient's baby at higher risk for?
- A. Intestinal problems
- B. Neonatal conjunctivitis
- C. Blindness
- D. Pneumonia
Correct Answer: B
Rationale: Step 1: The patient tested negative for chlamydia, syphilis, gonorrhea, and HIV, reducing the risk of transmission of these infections to the baby.
Step 2: Neonatal conjunctivitis is commonly caused by exposure to maternal genital tract bacteria during birth.
Step 3: Since the patient tested negative for the common infections, neonatal conjunctivitis becomes the higher risk for the baby.
Summary: A, C, and D are not directly related to the information provided, making them incorrect choices. Neonatal conjunctivitis is the most likely risk due to maternal genital tract bacteria exposure during birth.
During the fourth stage of labor, a nurse assesses the perineum of a birthing person who had a vaginal birth. What is the primary purpose of this assessment?
- A. to evaluate the birthing person's readiness for discharge
- B. to ensure the birthing person can ambulate safely
- C. to detect any signs of perineal trauma
- D. to assess the status of cervical dilation
Correct Answer: C
Rationale: The primary purpose of assessing the perineum during the fourth stage of labor is to detect any signs of perineal trauma. This assessment is crucial to identify any tears or lacerations that may require immediate medical attention. By checking for perineal trauma, the nurse can ensure proper healing and prevent complications postpartum.
Summary:
A: Evaluating readiness for discharge is not the primary purpose of perineal assessment during the fourth stage of labor.
B: Ensuring safe ambulation is important but not the primary reason for assessing the perineum.
D: Assessing cervical dilation is not relevant during the fourth stage of labor where the focus shifts to monitoring postpartum recovery.