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Induction of labor is planned for 31-year-old primigravida 39 weeks. She has insulin dependent diabetes. Which nursing action is more important?
- A. Begin Pitocin 4h after Cytotec (thin the cervix first)
- B. Administer 100mcg Cytotec q2h(no)
- C. Place vaginal gel and ambulate patient 1h
- D. Prepare to induce labor after administering tap water enema
Correct Answer: A
Rationale: The correct answer is A: Begin Pitocin 4h after Cytotec. This is the most important nursing action because it follows the recommended protocol for inducing labor in a diabetic patient. Cytotec is used to thin the cervix, and waiting 4 hours before starting Pitocin reduces the risk of uterine hyperstimulation, which can be dangerous for the mother and baby. Administering Cytotec every 2 hours (choice B) can increase the risk of hyperstimulation. Placing vaginal gel and ambulating the patient (choice C) may not be appropriate in this case as the patient has diabetes. Preparing to induce labor after administering a tap water enema (choice D) is not a priority compared to ensuring a safe induction process for a diabetic patient.
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Which nursing intervention can help prevent postpartum depression?
- A. Provide printed educational material
- B. Encourage the mother to join a support group
- C. Assess the mother for risk factors of depression
- D. Administer antidepressants as prescribed
Correct Answer: B
Rationale: The correct answer is B because joining a support group can provide emotional support and reduce feelings of isolation, which are key factors in preventing postpartum depression. Printed educational material (A) may not offer personalized support. Assessing for risk factors (C) is important but alone may not prevent depression. Administering antidepressants (D) is a treatment, not a prevention strategy.
The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
- A. Notify the health care provider of the findings.
- B. Reposition the mother and check the monitor for changes in the fetal tracing.
- C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
- D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. This is the most appropriate action because episodic accelerations in fetal heart rate patterns are a reassuring sign of fetal well-being. By documenting the findings and informing the mother of this, the nurse can provide reassurance and promote a positive birthing experience.
Choice A is incorrect because notifying the health care provider is not necessary for this normal finding. Choice B is incorrect because repositioning the mother and checking the monitor for changes is not needed when episodic accelerations are present. Choice C is incorrect because taking the mother's vital signs and prescribing bed rest is unnecessary and not indicated based on the fetal heart rate pattern.
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is
- A. Passed in first 12-24h of life
- B. Seen at 3 days
- C. Residue of a milk curd
- D. Lighter in color and looser in consistency
Correct Answer: A
Rationale: The correct answer is A because meconium stool is typically passed within the first 12-24 hours of life in newborns. Meconium is the earliest stool passed by a newborn and is composed of materials ingested while in the womb. Choices B, C, and D are incorrect because transitional stool is typically seen at 3 days, meconium is not a residue of milk curd, and meconium is darker in color and stickier in consistency compared to transitional stool.
A woman in labor reports a gush of fluid from her vagina. What is the nurse's first action?
- A. Check the fetal heart rate
- B. Assess the fluid for meconium staining
- C. Perform a sterile vaginal examination
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Check the fetal heart rate. This is the first action to assess the well-being of the fetus after the reported fluid gush, ensuring fetal safety. Checking fetal heart rate is crucial in determining fetal distress. Assessing for meconium staining (B) is important but comes after confirming fetal well-being. Performing a sterile vaginal examination (C) may introduce infection and should be avoided without proper indications. Notifying the healthcare provider (D) is necessary but should follow initial assessment of fetal status.