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The nurse is assisting with the preparation of a patient admitted for a planned cesarean birth. The patient has signed the consent form and discussed the elected regional anesthesia with the nurse anesthetist. Which is the most important action for the nurse related to anesthesia?
- A. Verify the patient has been NPO for 6 to 8 hours.
- B. Start an IV line and administer an IV fluid as ordered.
- C. Administer preoperative medications per orders.
- D. Obtain a baseline fetal heart rate monitor strip.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. NPO status is crucial to prevent aspiration during anesthesia administration.
2. Anesthesia guidelines typically require patients to be NPO for 6-8 hours.
3. Failure to verify NPO status can lead to serious complications.
4. Ensuring NPO status is a fundamental safety measure in anesthesia administration.
Summary of why other choices are incorrect:
B. Starting an IV and administering fluids are important but not as critical as verifying NPO status for anesthesia safety.
C. Administering preoperative medications is important, but ensuring NPO status takes precedence to prevent aspiration.
D. Obtaining a fetal heart rate monitor strip is important for monitoring the baby's well-being but does not directly impact anesthesia safety.
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Which statement correctly describes the nurse's responsibility related to electronic monitoring?
- A. Report abnormal findings to the physician before initiating corrective actions.
- B. Teach the woman and her support person about the monitoring equipment and discuss any of their questions.
- C. Document the frequency, duration, and intensity of contractions measured by the
- D. Inform the support person that the nurse will be responsible for all comfort
Correct Answer: B
Rationale: The correct answer is B because it aligns with the nurse's responsibility to educate and provide information to the patient and their support person. Teaching about the monitoring equipment and addressing any questions ensures that the patient and their support person are informed and empowered. This promotes patient understanding and involvement in their care, leading to better outcomes.
Choice A is incorrect because the nurse should initiate corrective actions promptly for abnormal findings without waiting for physician input. Choice C is incorrect as it focuses solely on documentation rather than patient education. Choice D is incorrect as it neglects the importance of involving the support person in the care process.
Which method of intrapartum fetal monitoring is the most appropriate when a woman has a history of hypertension during pregnancy?
- A. Continuous auscultation with a fetoscope
- B. Continuous electronic fetal monitoring
- C. Intermittent assessment with a Doppler transducer
- D. Intermittent electronic fetal monitoring for 15 minutes each hour
Correct Answer: B
Rationale: The correct answer is B: Continuous electronic fetal monitoring. This method is most appropriate for a woman with a history of hypertension during pregnancy because it allows continuous monitoring of fetal heart rate patterns and uterine contractions, providing real-time data to detect any signs of fetal distress promptly. Continuous monitoring is crucial in high-risk pregnancies to ensure timely intervention if any issues arise.
A: Continuous auscultation with a fetoscope is not ideal for a woman with a history of hypertension as it does not provide continuous monitoring and may miss subtle changes in fetal well-being.
C: Intermittent assessment with a Doppler transducer does not offer continuous monitoring, which is essential in high-risk pregnancies like hypertension.
D: Intermittent electronic fetal monitoring for 15 minutes each hour is not as effective as continuous monitoring in detecting changes in fetal well-being promptly, which is crucial in cases of hypertension during pregnancy.
Which clinical finding would be considered normal for a preterm fetus during the labor period?
- A. Baseline tachycardia
- B. Baseline bradycardia
- C. Fetal anemia
- D. Acidosis
Correct Answer: A
Rationale: The correct answer is A: Baseline tachycardia. During labor, it is normal for a preterm fetus to have a higher heart rate due to the stress of the labor process. This is a physiological response to the stress and is considered normal. Baseline bradycardia (choice B) would not be normal as it indicates fetal distress. Fetal anemia (choice C) can affect the oxygen-carrying capacity of the blood and lead to fetal distress. Acidosis (choice D) results from inadequate oxygen supply and accumulation of acid in the blood, indicating fetal distress.
What intervention may be used to manage failure to descend during labor?
- A. administering pain medication
- B. allowing the patient to rest
- C. continuing to push for an extended period of time
- D. using forceps or a vacuum to assist delivery
Correct Answer: D
Rationale: The correct answer is D because using forceps or a vacuum to assist delivery can help manage failure to descend during labor by aiding in the descent of the baby through the birth canal. Forceps or vacuum extraction can provide the necessary assistance to safely deliver the baby when maternal pushing alone is insufficient.
Explanation for why the other choices are incorrect:
A: Administering pain medication does not address the underlying issue of failure to descend during labor.
B: Allowing the patient to rest may not resolve the issue of failure to descend and could potentially delay necessary interventions.
C: Continuing to push for an extended period of time without progress can lead to maternal exhaustion and fetal distress without addressing the root cause of failure to descend.
What medication is administered to treat uterine atony?
- A. ampicillin
- B. nitroglycerine
- C. magnesium sulfate
- D. methylergonovine
Correct Answer: D
Rationale: The correct answer is D: methylergonovine. Methylergonovine is a uterotonic medication used to treat uterine atony by causing the uterus to contract and prevent postpartum hemorrhage. Ampicillin (A) is an antibiotic, nitroglycerine (B) is a vasodilator, and magnesium sulfate (C) is a medication used for conditions like preeclampsia and eclampsia, but not specifically for uterine atony. Therefore, D is the correct choice for treating uterine atony.