Nokea
The nurse is caring for a patient who is in labor and being externally monitored. What should the nurse do after noting early decelerations of the FHR?
- A. Anticipate a cesarean birth
- B. Turn the patient onto the left side
- C. Continue to monitor the patient
- D. Notify the physician or nurse midwife immediately
Correct Answer: C
Rationale: The correct answer is C: Continue to monitor the patient. Early decelerations are benign and occur due to head compression during contractions. They are a normal response to fetal head compression and do not require any intervention as they are self-limiting. Continuing to monitor the patient allows the nurse to observe the pattern of decelerations and ensure they remain early and resolve on their own. Anticipating a cesarean birth (choice A) is unnecessary as early decelerations do not indicate fetal distress. Turning the patient onto the left side (choice B) is typically done for late decelerations, not early decelerations. Notifying the physician or nurse midwife immediately (choice D) is not necessary for early decelerations as they are expected and do not require immediate intervention.
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Five minutes after delivery of the infant, the umbilical cord is protruding more from the woman's vaginal introitus and there is a sudden gush of blood with a contracted uterus. What does this signal to the nurse?
- A. Laceration of the genital tract
- B. The second stage of labor
- C. Separation of the placenta
- D. Postpartum hemorrhage
Correct Answer: C
Rationale: The sudden gush of blood and the contracted uterus indicate a separation of the placenta, which is a serious complication called placental abruption. This condition can lead to significant bleeding and jeopardize the health of both the mother and the baby. It is essential for the nurse to recognize this situation promptly and take immediate action to manage the hemorrhage and stabilize the patient.
Explanation for incorrect choices:
A: Laceration of the genital tract would not typically cause a sudden gush of blood and a contracted uterus.
B: The second stage of labor is characterized by the delivery of the baby, not by a sudden gush of blood and a contracted uterus.
D: Postpartum hemorrhage could be a consequence of placental separation, but it is not the primary issue indicated by the symptoms described in the scenario.
A pregnant patient at 28 weeks gestation is experiencing severe swelling in her hands and feet. Which of the following actions should the nurse take first?
- A. Assess the patient's blood pressure and check for signs of preeclampsia.
- B. Encourage the patient to elevate her legs and rest.
- C. Monitor the patient's urine output and report any changes.
- D. Schedule an ultrasound to assess fetal growth and amniotic fluid levels.
Correct Answer: A
Rationale: The correct action to take first is to assess the patient's blood pressure and check for signs of preeclampsia (Answer A). Preeclampsia is a serious condition characterized by high blood pressure and signs of organ dysfunction. In this scenario, the patient's severe swelling could be indicative of preeclampsia, which poses a risk to both the mother and the fetus. By assessing blood pressure and looking for other signs of preeclampsia, the nurse can determine the urgency of the situation and take appropriate actions to manage the condition.
Encouraging leg elevation and rest (Answer B) may help alleviate some symptoms but does not address the underlying cause of the swelling. Monitoring urine output (Answer C) is important for overall assessment but does not address the immediate concern of potential preeclampsia. Scheduling an ultrasound (Answer D) is not the priority in this situation as it does not provide information about the patient's current condition and does not address the
The nurse is monitoring her patient during labor and is aware that the only way to determine the objective measurement of uterine contractions is through the use of which modality?
- A. Tocodynamometer
- B. Fetal spiral electrode
- C. IUPC
- D. Palpation
Correct Answer: C
Rationale: The correct answer is C: IUPC (Intrauterine Pressure Catheter). This modality is the only direct and objective measurement of uterine contractions as it provides continuous and precise readings of intrauterine pressure. A: Tocodynamometer measures frequency and duration, but not intensity. B: Fetal spiral electrode monitors fetal heart rate, not uterine contractions. D: Palpation is subjective and not as accurate as IUPC for measuring uterine contractions.
A nurse is preparing a laboring person for an epidural. What is the priority nursing intervention before the procedure?
- A. ensure informed consent
- B. check for allergies to anesthesia
- C. assess for fetal movement
- D. administer pain relief
Correct Answer: C
Rationale: The correct answer is C: assess for fetal movement. This is the priority intervention before an epidural to ensure the safety and well-being of the fetus. Assessing for fetal movement helps determine the fetal well-being and any potential distress that may require immediate intervention. Ensuring informed consent (A) is important but assessing fetal well-being takes precedence. Checking for allergies to anesthesia (B) is important but not the priority before assessing fetal movement. Administering pain relief (D) can be done after assessing fetal movement to ensure the safety of both the laboring person and the fetus.
A nurse is educating a birthing person about the signs and symptoms of postpartum hemorrhage. Which of the following is an early sign of postpartum hemorrhage?
- A. bright red bleeding
- B. increased blood pressure
- C. severe abdominal pain
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: bright red bleeding. This is an early sign of postpartum hemorrhage because it indicates active bleeding from the uterus. Bright red blood suggests fresh bleeding, which is more concerning than darker blood. Increased blood pressure (B) is not typically associated with postpartum hemorrhage. Severe abdominal pain (C) is more indicative of other complications like uterine rupture. Increased heart rate (D) can be a sign of postpartum hemorrhage, but bright red bleeding is a more specific early indicator.