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The nurse is preparing a patient for a cesarean birth scheduled to be performed under general
- A. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents? (Select all that apply.)
- B. Citric acid (Bicitr
- C. Bromocriptine (Parlodel)
- D. Ranitidine (Zanta
Correct Answer: B
Rationale: The correct answer is B: Citric acid (Bicitr). Citric acid helps decrease the acidity of gastric contents, reducing the risk of aspiration during general anesthesia. Citric acid works as an antacid and helps neutralize stomach acid, which can help prevent complications during surgery.
Incorrect choices:
A: This choice is incorrect because it does not address the prevention of aspiration of gastric contents.
C: Bromocriptine is a medication used to treat conditions like hyperprolactinemia and Parkinson's disease. It is not indicated for preventing aspiration during surgery.
D: Ranitidine is an H2 blocker used to reduce stomach acid production. While it can help with heartburn and acid reflux, it is not typically used to prevent aspiration during surgery.
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If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to
- A. massage the fundus.
- B. take the blood pressure
- C. increase blood supply to the hands and feet.
- D. notify the physician or nurse-midwif
Correct Answer: A
Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.
Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?
- A. Anterior fontanel
- B. Coronal suture lines
- C. Posterior fontanel
- D. Biparietal diameter
Correct Answer: C
Rationale: The correct answer is C: Posterior fontanel. When a vacuum extractor is used during birth, it can cause swelling or molding of the baby's head, which may affect the assessment of the posterior fontanel. This fontanel is an important landmark for determining head size and shape. Swelling or molding can make it difficult to accurately assess the fontanel's size and shape, potentially impacting the overall assessment of the newborn's head.
A: The anterior fontanel is not typically affected by the use of a vacuum extractor.
B: The coronal suture lines are not directly impacted by the vacuum extractor.
D: The biparietal diameter can still be measured accurately even with molding caused by the vacuum extractor.
Which intervention is an essential part of nursing care for a laboring patient?
- A. Helping the woman manage the pain
- B. Eliminating the pain associated with labor
- C. Feeling comfortable with the predictable nature of intrapartal care
- D. Sharing personal experiences regarding labor and birth to decrease her anxiety
Correct Answer: A
Rationale: The correct answer is A because helping the woman manage the pain is essential in nursing care for a laboring patient to ensure her comfort and well-being during labor. This intervention includes providing pain relief measures, such as positioning, massage, breathing techniques, and administering pain medication if needed. The focus is on supporting the woman's coping mechanisms and enhancing her overall birthing experience.
Choice B is incorrect because eliminating pain completely is not always possible or recommended in labor, as some pain is a natural part of the process. Choice C is incorrect as comfort with the predictable nature of care is not as crucial as providing active pain management. Choice D is incorrect because sharing personal experiences may not be relevant or helpful to the laboring patient and may not address her specific needs during labor.
A laboring patient experiences a sudden rupture of membranes and the nurse observes a prolapsed cord. What is the nurse's priority action?
- A. Reposition the patient to relieve pressure on the cord.
- B. Immediately prepare the patient for a cesarean delivery.
- C. Administer oxygen at 10 L/min.
- D. Monitor the fetal heart rate continuously.
Correct Answer: A
Rationale: The correct answer is A: Reposition the patient to relieve pressure on the cord. This is the priority action because a prolapsed cord can lead to fetal compromise due to decreased blood flow. By repositioning the patient to a knee-chest or Trendelenburg position, gravity helps alleviate pressure on the cord. This action is crucial to prevent further compromise to the fetus.
Incorrect Choices:
B: Immediately prepare the patient for a cesarean delivery - While this may be necessary eventually, the immediate priority is to relieve pressure on the cord.
C: Administer oxygen at 10 L/min - Oxygen may be needed, but it is not the priority action in this emergency situation.
D: Monitor the fetal heart rate continuously - Monitoring is important, but repositioning the patient to relieve cord compression takes precedence.
The nurse is reviewing the cardinal maneuvers of labor and birth with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head?
- A. Expulsion
- B. Restitution
- C. Internal rotation
- D. External rotation
Correct Answer: A
Rationale: After the baby's head is born, the immediate next step is the expulsion of the baby's body. This is because the expulsion maneuver refers to the delivery of the rest of the baby's body following the birth of the head. Restitution, internal rotation, and external rotation occur before the birth of the baby's head and are part of the cardinal movements of labor and birth. Restitution involves the realignment of the baby's head with their body after the head is born. Internal rotation refers to the baby's head turning to navigate through the birth canal. External rotation involves the baby's head turning back to its original position after delivery. So, the correct answer is A (Expulsion), as it directly follows the birth of the baby's head.