Nokea
A woman in labor requests an epidural. What should the nurse assess before administering the epidural?
- A. Cervical dilation
- B. Maternal blood pressure
- C. Fetal heart rate
- D. Maternal temperature
Correct Answer: B
Rationale: The correct answer is B: Maternal blood pressure. Before administering an epidural, it is crucial to assess the maternal blood pressure to ensure it is within the normal range. Hypotension can occur as a common side effect of epidural anesthesia, which can lead to decreased placental perfusion and compromise fetal oxygenation. Assessing maternal blood pressure helps in preventing potential complications.
Incorrect choices:
A: Cervical dilation - Not directly related to the administration of an epidural.
C: Fetal heart rate - Important but not the immediate assessment needed before administering an epidural.
D: Maternal temperature - While it is important in general assessment, it is not specifically required before giving an epidural.
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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 laboring person who is receiving oxytocin for induction of labor. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate continuously
- B. increase maternal hydration
- C. administer IV fluids
- D. assess uterine tone
Correct Answer: C
Rationale: The correct answer is C because administering IV fluids is crucial during oxytocin infusion to prevent maternal dehydration and maintain fluid balance. This helps prevent complications such as uterine hyperstimulation and fetal distress. Monitoring fetal heart rate continuously (choice A) is important but not the priority. Increasing maternal hydration (choice B) is beneficial but does not address the immediate need for fluid replacement. Assessing uterine tone (choice D) is important but secondary to ensuring adequate hydration.
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.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during this stage?
- A. coach the person through controlled pushing
- B. assist with spontaneous pushing
- C. assist with deep breathing
- D. offer non-pharmacological pain relief
Correct Answer: B
Rationale: The correct answer is B because in the second stage of labor, it is appropriate to assist the laboring person with spontaneous pushing to facilitate the descent of the baby through the birth canal. Controlled pushing (choice A) may cause fatigue and unnecessary strain. Deep breathing (choice C) is more suitable for the first stage of labor. Non-pharmacological pain relief (choice D) can be helpful but is not the priority in the second stage when the focus should be on pushing effectively.
A pregnant patient with a BMI of 35 is concerned about health effects she and her baby may face during pregnancy. During routine testing, the patient tested negative for sexually transmitted illnesses (STIs) and indicated that she is in a committed, long-term relationship with the child's father. Which of the following is accurate?
- A. The patient's infant is at increased risk of neonatal blindness.
- B. The patient's infant has a decreased risk of birth injury.
- C. The patient will have increased risk of wound infection.
- D. The patient will have a decreased risk of preeclampsia.
Correct Answer: C
Rationale: Rationale:
1. Pregnancy with a high BMI increases the risk of wound infection post-delivery due to delayed wound healing and increased tissue trauma.
2. Negative STI test and committed relationship decrease risks of neonatal blindness and birth injury.
3. Wound infection risk is directly related to BMI and not affected by STI status or relationship status.
Summary:
A: Incorrect - No connection between STI status or relationship status with neonatal blindness.
B: Incorrect - No direct relation between STI status or relationship status with birth injury risk.
D: Incorrect - Preeclampsia risk is not influenced by STI status or relationship status.