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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.
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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.
A 26-year-old multigravida patient is 14 weeks pregnant and is scheduled for a maternal serum alpha-fetoprotein test. She asks the nurse, 'What does this test indicate?' The nurse explains that this test can detect which of the following?
- A. Leg defects
- B. Gastrointestinal defects
- C. Neural tube defects
- D. Renal defects
Correct Answer: C
Rationale: Quickening is the term used when a woman feels the first fetal movements. It typically happens around the second trimester and is a sign of fetal development and activity.
A nurse is performing an initial assessment of a multigravida patient who is 10 weeks gestation. Which assessment finding would necessitate further testing?
- A. Rubella titer ratio of 1:10
- B. Blood type A+
- C. White blood cell count of 5,000
- D. Previous history of gestational diabetes
Correct Answer: A
Rationale: Chadwick’s sign, which is the bluish coloration of the cervix, is an early positive sign of pregnancy. It indicates increased blood flow and is often noted during a pelvic examination.
A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action?
- A. Stop the infusion of Pitocin.
- B. Reposition the patient from her right to her left side
- C. Perform a vaginal exam to assess for a prolapsed cord
- D. Perform a vaginal exam to assess for a prolapsed cor
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to stop the infusion of Pitocin. Late decelerations are a concerning fetal heart rate pattern that indicates uteroplacental insufficiency. Oxytocin (Pitocin) can cause hyperstimulation of the uterus, leading to poor oxygenation of the fetus and resulting in late decelerations. Stopping the Pitocin infusion can help to improve placental perfusion and oxygenation to the fetus, potentially reversing the late decelerations. It is crucial to address the fetal distress promptly to prevent further compromise and ensure the safety of both the mother and the baby. Other interventions, such as repositioning the patient or preparing for a cesarean birth, may also be necessary but should occur after stopping the Pitocin infusion.
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.