Nokea
What is the most appropriate nursing diagnosis?
- A. Anxiety related to the development of postpartum complications
- B. Ineffective individual coping related to unfamiliarity with procedures
- C. Risk for ineffective parenting related to emergency cesarean section
- D. Grieving related to loss of expected birth experience
Correct Answer: D
Rationale: Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger, because the expected course of birth did not occur.
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What nursing actions will the nurse anticipate implementing?
- A. Insert IV.
- B. Record a baseline fetal heart rate.
- C. Explain procedure to patient.
- D. Instruct patient to ambulate immediately afterward.
- E. Ensure a tocolytic is available.
Correct Answer: A,B,C
Rationale: The cervical ripening procedure should be explained, a fetal heart rate baseline recorded, and an IV line placed in case tocolytics are needed for uterine tachysystole.
What position will the nurse promote to encourage fetal rotation and pain relief?
- A. Prone with legs supported and give her a back massage
- B. Supine with legs bent at the knee
- C. Standing with support
- D. Sitting up and leaning forward on the overbed table
Correct Answer: D
Rationale: A position that favors fetal rotation and descent and is helpful for the woman with back labor is to sit or kneel leaning forward on a support.
What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
- A. Warm compresses to the perineum
- B. Cold pack to the perineum
- C. Warm sitz bath
- D. Elevation of hips to prevent edema
Correct Answer: B
Rationale: Ice is applied to the perineum to reduce bruising and edema.
What side effect should the nurse inform the patient that she might experience?
- A. Nausea and vomiting
- B. Headache
- C. Warm flush
- D. Urinary frequency
Correct Answer: C
Rationale: Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.
What is the most appropriate pain-relief intervention for a woman in precipitate labor?
- A. Get an order for an intravenous narcotic.
- B. Notify the anesthesiologist for an epidural block.
- C. Stay and breathe with her during contractions.
- D. Tell her to bear with it because she is close to delivery.
Correct Answer: C
Rationale: The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.