Nokea
The nurse is monitoring a patient who has been in prolonged labor. Which assessment finding will result in the nurse notifying the health care provider about the development of an emergent situation requiring a cesarean delivery?
- A. Maternal blood pressure indicative of hypotension
- B. Maternal exhaustion from prolonged uterine activity
- C. Recognition of a Category II fetal heart rate pattern
- D. Increased maternal temperature related to infection
Correct Answer: C
Rationale: The correct answer is C: Recognition of a Category II fetal heart rate pattern. This indicates fetal distress and potential compromise to the baby's well-being, necessitating immediate intervention like a cesarean delivery to prevent adverse outcomes. A: Maternal hypotension may require intervention but is not an emergent indication for a cesarean section. B: Maternal exhaustion can be managed with support and rest, not an immediate indication for cesarean delivery. D: Maternal fever may indicate infection but does not necessarily require cesarean delivery unless it poses a significant risk to the baby.
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When a pattern of variable decelerations occur, the nurse should immediately
- A. administer O at 8 to 10 L/minut
- B. place a wedge under the right hip.
- C. increase the IV fluids to 150 mL/hour.
- D. position patient in a knee-chest position.
Correct Answer: D
Rationale: The correct answer is D because positioning the patient in a knee-chest position helps to relieve pressure on the vena cava, improving blood flow to the placenta and fetus. This can help alleviate variable decelerations. Choice A is incorrect because administering oxygen at 8 to 10 L/min would not directly address the cause of variable decelerations. Choice B is incorrect as placing a wedge under the right hip is typically used for supine hypotension syndrome. Choice C is incorrect because increasing IV fluids may not directly address the issue of variable decelerations.
A nurse has recently transferred to a labor and delivery unit. During a scheduled cesarean, the nurse notices a prescription for the administration of 1,000 mL of prewarmed IV fluid. For which reason does the health care provider prescribe the fluid in this manner? Select all that apply.
- A. Results in an increased maternal core temperature
- B. Results in improved neonatal umbilical arterial pH
- C. Results in improved Apgar scores
- D. Results in decreased risk for maternal shock
Correct Answer: A
Rationale: Step 1: IV fluid is prewarmed to prevent hypothermia in the mother during cesarean delivery, which can occur due to exposure to cold operating room environment.
Step 2: Hypothermia in the mother can lead to adverse outcomes such as increased blood loss, delayed wound healing, and increased risk of infection.
Step 3: Maintaining maternal normothermia through prewarmed IV fluids is crucial for optimal maternal outcomes during cesarean delivery.
Summary:
- B: Improved neonatal umbilical arterial pH is not directly related to prewarmed IV fluid administration.
- C: Apgar scores are primarily influenced by factors like neonatal resuscitation and immediate care, not IV fluid temperature.
- D: Prewarmed IV fluid administration is more about preventing hypothermia in the mother rather than decreasing the risk for maternal shock.
A 20-year-old gravida 1 para 0 presents to the prenatal clinic with a chief complaint that she feels like she is pregnant. Which are presumptive signs of pregnancy? Select all that apply.
- A. Linea nigra
- B. Breast tenderness
- C. Leukorrhea
- D. Chadwick’s sign
Correct Answer: A
Rationale: The correct answer is A: Linea nigra. Linea nigra is a presumptive sign of pregnancy, which refers to a dark line that appears on the abdomen. This sign is caused by hormonal changes during pregnancy. Breast tenderness (B) and leukorrhea (C) are actually probable signs of pregnancy, not presumptive signs. Chadwick's sign (D) is also a probable sign, not a presumptive sign. Presumptive signs are subjective symptoms reported by the patient and are not definitive indicators of pregnancy.
What complication makes uterine inversion an emergency?
- A. shock
- B. pain
- C. retained placenta
- D. hypertension
Correct Answer: A
Rationale: The correct answer is A: shock. Uterine inversion is an emergency due to the risk of shock. When the uterus turns inside out, it can lead to severe bleeding and disruption of blood flow, causing hypovolemic shock. This can be life-threatening if not promptly addressed. Pain (choice B) and retained placenta (choice C) are potential complications of uterine inversion but do not pose the immediate threat of shock. Hypertension (choice D) is not directly related to the urgency of uterine inversion.
Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.)
- A. Oxytocin (Pitocin)
- B. Misoprostol (Cytote
- C. Dinoprostone (Cervidil)
- D. Methylergonovine maleate (Methergin
Correct Answer: A
Rationale: The correct answer is A: Oxytocin (Pitocin). Oxytocin is a uterotonic agent commonly used to induce or augment labor. It can cause hyperstimulation of the uterus, leading to uterine hypertonicity and potentially compromising fetal oxygenation. Misoprostol, Dinoprostone, and Methylergonovine maleate are not known to cause hyperstimulation of the uterus during labor.