Nokea
What is the best nursing action to implement when late decelerations occur?
- A. Reposition the patient to supine.
- B. Decrease flow of intravenous (IV) fluids.
- C. Increase oxygen to 10 L/minute.
- D. Prepare to increase oxytocin drip.
Correct Answer: C
Rationale: The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.
You may also like to solve these questions
What does the nurse note when measuring the frequency of a laboring woman's contractions?
- A. How long the patient states the contractions last
- B. The time between the end of one contraction and the beginning of the next
- C. The time between the beginning and the end of one contraction
- D. The time between the beginning of one contraction and the beginning of the next
Correct Answer: D
Rationale: The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.
It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. How would the nurse record this presentation?
- A. Complete breech
- B. Frank breech
- C. Double footing
- D. Buttocks presentation
Correct Answer: B
Rationale: When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.
The nurse knows that what indicates the beginning of true labor?
- A. Contractions that are relieved by walking
- B. Discomfort in the abdomen and groin
- C. A decrease in vaginal discharge
- D. Regular contractions becoming more frequent and intense
Correct Answer: D
Rationale: In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.
What is the function of contractions during the second stage of labor?
- A. Align the infant into the proper position for delivery.
- B. Dilate and efface the cervix.
- C. Push the infant out of the mother's body.
- D. Separate the placenta from the uterine wall.
Correct Answer: C
Rationale: The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant.
The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.