Nokea
What is the most common indication for performing an episiotomy?
- A. to prevent severe perineal tears
- B. to allow the birth to occur more quickly
- C. to relieve the risk of shoulder dystocia
- D. to control excessive vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: to control excessive vaginal bleeding. Episiotomy is primarily performed to manage and control postpartum hemorrhage by facilitating better visualization and access for suturing any bleeding vessels. It is not routinely done for preventing severe tears, expediting birth, or addressing shoulder dystocia, as there are alternative interventions for these situations. Episiotomy should be carefully considered and performed only when necessary to avoid unnecessary complications and promote better outcomes.
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A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.
A laboring person on oxytocin for induction of labor should have continuous monitoring of the fetal heart rate. How often should the nurse assess the fetal heart rate?
- A. every 30 minutes
- B. every 15 minutes
- C. every 5 minutes
- D. every 1 hour
Correct Answer: B
Rationale: The correct answer is B: every 15 minutes. Continuous monitoring of the fetal heart rate is crucial during labor induction with oxytocin to promptly detect any signs of fetal distress. Assessing the fetal heart rate every 15 minutes allows for frequent monitoring to ensure the baby's well-being and timely intervention if needed. Assessing every 30 minutes (choice A) may not provide adequate monitoring frequency, every 5 minutes (choice C) is too frequent and may not be practical, and every 1 hour (choice D) is too long of an interval between assessments, potentially missing important changes in fetal status.
A 36-week gestation gravid lies flat on her back.
- A. Hypertension.
- B. Dizziness.
- C. Rales.
- D. Chloasma.
Correct Answer: B
Rationale: Lying flat on the back can compress the inferior vena cava, leading to reduced blood flow and dizziness. Chloasma, rales, and hypertension are unrelated to this position.
A nurse is preparing to administer a postpartum tetanus shot. What is the most important action before administering the shot?
- A. verify the person's immunization status
- B. assess the person's blood pressure
- C. assess for uterine atony
- D. prepare for a cesarean section
Correct Answer: C
Rationale: Rationale:
C is correct because assessing for uterine atony is crucial before administering a postpartum tetanus shot to ensure no postpartum hemorrhage risk. Uterine atony can lead to excessive bleeding, which can be exacerbated by the tetanus shot.
Summary:
A - Verifying immunization status is important but not the most immediate action.
B - Assessing blood pressure is important but not directly related to the risk of postpartum hemorrhage.
D - Preparing for a cesarean section is not necessary for administering a postpartum tetanus shot.
A woman, 6 weeks pregnant, is having a vaginal examination. Which of the following would the practitioner expect to find?
- A. Thin cervical muscle.
- B. An enlarged ovary.
- C. Thick cervical mucus.
- D. Pale pink vaginal wall.
Correct Answer: B
Rationale: An enlarged ovary is a common finding in early pregnancy due to the corpus luteum. Thin cervical muscle, thick cervical mucus, and a pale pink vaginal wall are not typical findings at this stage.