Nokea
The nurse will monitor for aspiration, thought processes, and improved mobility after which complication?
- A. neurologic dysfunction
- B. Measure blood loss.
- C. gestational diabetes
- D. postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: postpartum hemorrhage. The nurse monitors for aspiration due to potential bleeding or clotting issues postpartum. Monitoring thought processes is important as postpartum hemorrhage can lead to hypovolemic shock affecting cognition. Improved mobility is assessed as excessive bleeding can cause weakness. Neurologic dysfunction (choice A) is not directly related to postpartum hemorrhage. Measuring blood loss (choice B) is important but not the primary focus after postpartum hemorrhage. Gestational diabetes (choice C) is a separate condition unrelated to postpartum hemorrhage.
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Which clinical finding would be considered normal for a preterm fetus during the labor period?
- A. Baseline tachycardia
- B. Baseline bradycardia
- C. Fetal anemia
- D. Acidosis
Correct Answer: A
Rationale: The correct answer is A: Baseline tachycardia. During labor, it is normal for a preterm fetus to have a higher heart rate due to the stress of the labor process. This is a physiological response to the stress and is considered normal. Baseline bradycardia (choice B) would not be normal as it indicates fetal distress. Fetal anemia (choice C) can affect the oxygen-carrying capacity of the blood and lead to fetal distress. Acidosis (choice D) results from inadequate oxygen supply and accumulation of acid in the blood, indicating fetal distress.
Which of the following is theN pUriRorSitIy NinGteTrvBen.tiConO fMor the patient in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction?
- A. Administer O at 8 to 10 L/minut
- B. Decrease the IV rate to 100 mL/hour.
- C. Reposition the ultrasound transducer.
- D. Perform a vaginal exam to assess for cord prolaps
Correct Answer: A
Rationale: The correct answer is A: Administer O at 8 to 10 L/minut. In a left side-lying position, this deceleration indicates possible umbilical cord compression, reducing oxygen supply to the fetus. Administering oxygen at 8 to 10 L/min can help improve fetal oxygenation. Decreasing the IV rate (B) wouldn't directly address the fetal distress. Repositioning the ultrasound transducer (C) is irrelevant to the situation. Performing a vaginal exam (D) could worsen the cord compression if the cord is prolapsed.
In preparation for a cesarean birth, the nurse expects which medical-based preoperative interventions? Select all that apply.
- A. Administration of narrow-spectrum prophylactic antibiotics
- B. Verification that the woman has been NPO for 6 to 8 hours before surgery
- C. Assessment of the woman’s knowledge and educational needs
- D. Assessment for risk of venous thromboembolism (VTE)
Correct Answer: B
Rationale: The correct answer is B because being NPO (nothing by mouth) for 6 to 8 hours before surgery helps prevent aspiration during anesthesia. Option A is incorrect because broad-spectrum antibiotics are typically used to cover a wider range of potential pathogens. Option C is not a medical-based preoperative intervention. Option D, while important, is more related to postoperative care rather than preoperative interventions.
How soon should delivery of the fetus occur when a Category III FHR tracing is diagnosed?
- A. 15 minutes
- B. 30 minutes
- C. 45 minutes
- D. 60 minutes
Correct Answer: B
Rationale: The correct answer is B: 30 minutes. When a Category III FHR tracing is diagnosed, it indicates severe fetal distress. Prompt delivery is crucial to prevent adverse outcomes. 30 minutes allows for timely intervention without risking further harm to the fetus. Option A (15 minutes) may be too rushed, potentially causing unnecessary stress during the delivery process. Options C (45 minutes) and D (60 minutes) delay delivery, increasing the risk of complications due to prolonged fetal distress. Timing is critical in ensuring the best possible outcome for both the mother and the baby.
The physician has ordered an amnioinfusion for the laboring patient. Which data supports the use of this therapeutic procedure?
- A. Presenting part not engaged
- B. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM)
- C. Breech position of fetus
- D. Twin gestation
Correct Answer: B
Rationale: The correct answer is B because +4 meconium-stained amniotic fluid on AROM indicates meconium passage by the fetus, which can lead to meconium aspiration syndrome. Amnioinfusion can help dilute the meconium, reducing the risk of respiratory complications for the newborn.
A: Presenting part not engaged is not a direct indication for amnioinfusion.
C: Breech position of the fetus does not specifically warrant amnioinfusion.
D: Twin gestation alone is not a direct indication for amnioinfusion.