Nokea
The nurse is providing care for a patient who delivered via cesarean 24 hours ago. Which teaching does the nurse provide for the patient and family? Select all that apply.
- A. Signs and symptoms to report to health care provider
- B. Comfortable positions for feeding the newborn
- C. Encouragement for early dietary intake of solid foods
- D. Encourage family to help with infant care and housework
Correct Answer: D
Rationale: Choice A is correct. Postoperative teaching should focus on signs of complications, such as infection, thrombosis, and how to manage pain. Early ambulation is encouraged to reduce risks like deep vein thrombosis.
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Proper placement of the tocotransducer for electronic fetal monitoring is
- A. Inside the uterus.
- B. On the fetal scalp.
- C. Over the uterine fundus.
- D. Over the mother's lower abdomen.
Correct Answer: C
Rationale: The tocotransducer is a device used for electronic fetal monitoring to measure uterine contractions. Proper placement of the tocotransducer is over the uterine fundus, which is the upper part of the uterus where contractions are most accurately detected. Placing the tocotransducer there allows for optimal monitoring of uterine activity during labor, ensuring accurate readings and appropriate interventions if necessary. Placing the tocotransducer inside the uterus, on the fetal scalp, or over the mother's lower abdomen would not provide accurate readings of uterine contractions.
If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen?
- A. Right upper
- B. Left upper
- C. Right lower
- D. Left lower
Correct Answer: C
Rationale: When the fetus is in a right occiput anterior position, the back of the fetus is on the mother's right side, and the fetal heart is also located on the right side of the mother's abdomen. It is typically heard in the lower right quadrant due to the location of the fetal back and heart. The nurse should assess the fetal heart rate in the right lower quadrant of the maternal abdomen to accurately assess the well-being of the fetus in this position.
The nurse is providing care for a prenatal patient who is told she will require a cesarean delivery because of cephalopelvic disproportion. Which explanation of the condition will the nurse provide to the patient?
- A. The patient has a preexisting medical condition that supports cesarean birth.
- B. The size and/or shape of either the fetal head or patient pelvis is an issue.
- C. The placenta is implanted in an unfavorable position in the uterus.
- D. The patient had a surgery with an incision through the myometrium of the uterus.
Correct Answer: B
Rationale: Choice B is the correct answer because cephalopelvic disproportion refers to a situation where the size or shape of the fetal head or the mother's pelvis causes difficulty during vaginal birth. This is the most accurate explanation for why a cesarean may be required.
A patient is being prepared for an unplanned cesarean section. Which pre-procedure information is most important for the nurse to report before the administration of regional anesthesia?
- A. Hypovolemia corrected with IV fluid administration
- B. Inability of the patient to sit on the bedside and flex forward
- C. Laboratory value indicating a low platelet count
- D. History of patient experiencing headaches after a spinal
Correct Answer: C
Rationale: Choice C is the correct answer because a low platelet count indicates a risk for bleeding, and regional anesthesia can be dangerous in such cases due to the possibility of epidural or spinal hematoma.
What medication should the nurse anticipate administering when caring for a person with preeclampsia in labor?
- A. ampicillin
- B. magnesium sulfate
- C. nalbuphine hydrocholoride (Nubain)
- D. sodium bicarbonate
Correct Answer: B
Rationale: Magnesium sulfate is commonly administered for preeclampsia in labor.