Nokea
At what point is the second stage considered prolonged for a nulliparous laboring person?
- A. 1 hour
- B. 2 hours
- C. 3 hours
- D. 4 hours
Correct Answer: B
Rationale: The second stage is considered prolonged after 2 hours in a nulliparous laboring person.
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The nurse is providing care for a patient who delivered via cesarean 24 hours ago. Which teaching does the nurse provide for the patient and family? Select all that apply.
- A. Signs and symptoms to report to health care provider
- B. Comfortable positions for feeding the newborn
- C. Encouragement for early dietary intake of solid foods
- D. Encourage family to help with infant care and housework
Correct Answer: D
Rationale: Choice A is correct. Postoperative teaching should focus on signs of complications, such as infection, thrombosis, and how to manage pain. Early ambulation is encouraged to reduce risks like deep vein thrombosis.
What medication should the nurse anticipate administering when caring for a person with preeclampsia in labor?
- A. ampicillin
- B. magnesium sulfate
- C. nalbuphine hydrocholoride (Nubain)
- D. sodium bicarbonate
Correct Answer: B
Rationale: Magnesium sulfate is commonly administered for preeclampsia in labor.
A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action?
- A. Stop the infusion of Pitocin.
- B. Reposition the patient from her right to her left side
- C. Perform a vaginal exam to assess for a prolapsed cord
- D. Perform a vaginal exam to assess for a prolapsed cor
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to stop the infusion of Pitocin. Late decelerations are a concerning fetal heart rate pattern that indicates uteroplacental insufficiency. Oxytocin (Pitocin) can cause hyperstimulation of the uterus, leading to poor oxygenation of the fetus and resulting in late decelerations. Stopping the Pitocin infusion can help to improve placental perfusion and oxygenation to the fetus, potentially reversing the late decelerations. It is crucial to address the fetal distress promptly to prevent further compromise and ensure the safety of both the mother and the baby. Other interventions, such as repositioning the patient or preparing for a cesarean birth, may also be necessary but should occur after stopping the Pitocin infusion.
With what is malnutrition during pregnancy associated?
- A. fetal growth restriction
- B. postterm birth
- C. uterine dystocia
- D. precipitous birth
Correct Answer: A
Rationale: Malnutrition during pregnancy can lead to fetal growth restriction.
The nurse is educating a primigravida patient during her first prenatal clinic appointment about follow-up prenatal care. How often will follow-up prenatal clinic visits be scheduled if the patient has a low-risk pregnancy and develops no complications? Select all that apply.
- A. Every 2 weeks for the first 28 weeks
- B. Every 4 weeks until 30 weeks
- C. Every 4 weeks until 28 weeks
- D. Every 2 weeks after 28 completed weeks until 36 weeks gestation
Correct Answer: C
Rationale: Ballottement is a physical examination technique used to detect the presence of a floating fetus or other abnormalities. A gentle tap on the cervix causes a rebound or sensation, confirming fetal presence.