Nokea
The nurse is assisting a couple to develop decisions for their birth plan. Which of the following decisions should be considered nonnegotiable by the parents?
- A. Whether or not the father will be present during labor.
- B. Whether or not the woman will have an episiotomy.
- C. Whether or not the woman will be able to have an epidural.
- D. Whether or not the father will be able to take pictures of the delivery.
Correct Answer: A
Rationale: The decision regarding the father's presence during labor is deeply personal and should respect the parents' wishes. Medical interventions like episiotomy or epidural can involve clinical judgment, but the presence of a partner is entirely up to the parents.
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The nurse is caring for a pregnant patient who is at 30 weeks gestation and is diagnosed with preterm labor. What intervention is the nurse likely to implement first?
- A. Administering corticosteroids to enhance fetal lung maturity
- B. Administering magnesium sulfate to prevent seizures
- C. Administering antibiotics to prevent infection
- D. Starting a medication to stop the contractions
Correct Answer: A
Rationale: The correct answer is A: Administering corticosteroids to enhance fetal lung maturity. Administering corticosteroids is the priority intervention in preterm labor at 30 weeks gestation as it helps accelerate fetal lung maturity, reducing the risk of respiratory distress syndrome. This intervention is crucial in improving neonatal outcomes. Administering magnesium sulfate (Choice B) is used to prevent seizures in preeclampsia, not preterm labor. Administering antibiotics (Choice C) is not the priority in preterm labor unless there is evidence of infection. Starting a medication to stop contractions (Choice D) may be necessary, but enhancing fetal lung maturity takes precedence to improve the baby's respiratory status.
The nurse is providing anticipatory guidance to a woman in her second trimester regarding signs/symptoms that are within normal limits during the latter half of the pregnancy.
- A. During the third trimester I may experience frequent urination.
- B. During the third trimester I may experience heartburn.
- C. During the third trimester I may experience nagging backaches.
- D. During the third trimester I may experience persistent headache.
Correct Answer: A
Rationale: Frequent urination, heartburn, and backaches are common during the third trimester due to the growing uterus putting pressure on the bladder and digestive system, as well as changes in posture. Persistent headaches are not normal and should be reported.
A nurse is assisting a laboring person with a vacuum extraction. What is the most important nursing action to ensure a safe procedure?
- A. monitor fetal heart rate continuously
- B. prepare the person for a cesarean section
- C. monitor for signs of uterine rupture
- D. assist with positioning the person
Correct Answer: B
Rationale: The correct answer is B: prepare the person for a cesarean section. In the scenario of vacuum extraction, if there are complications or the procedure is unsuccessful, the person may need to undergo an emergency cesarean section. By preparing the person for this possibility, the nurse ensures timely intervention if needed, prioritizing the safety of both the person and the baby. Monitoring fetal heart rate continuously (A) is important but not the most crucial action in this case. Monitoring for signs of uterine rupture (C) is not directly related to vacuum extraction. Assisting with positioning (D) is important but not as critical as preparing for a potential cesarean section.
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.
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.