Nokea
What is the nursing intervention for prolapsed cord?
- A. Turn the person to the side.
- B. Give the person oxygen.
- C. Lift the presenting part off the cord.
- D. Increase the oxytocin.
Correct Answer: C
Rationale: The correct nursing intervention for prolapsed cord is to lift the presenting part off the cord to relieve pressure and improve blood flow to the fetus. This step prevents further compression of the blood vessels in the cord. Turning the person to the side (A) is not specific to addressing a prolapsed cord. Giving oxygen (B) may be necessary, but it does not directly address the issue of cord prolapse. Increasing oxytocin (D) can worsen the situation by causing stronger contractions, potentially further compressing the cord. Therefore, the most appropriate action is to lift the presenting part off the cord (C) to protect the blood flow to the fetus.
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The nurse-manager on a labor and delivery unit is monitoring the reasons for cesarean births at the facility. Which reasons contribute to the high rates of cesarean births? Select all that apply.
- A. Fetuses in breech position unable to deliver vaginally
- B. Increased number of elective or maternal request cesareans
- C. Incidences of women of older maternal age getting pregnant
- D. Decreasing rate of malpractice litigation with cesarean birth
Correct Answer: B
Rationale: The correct answer is B: Increased number of elective or maternal request cesareans. This is correct because the rise in elective cesarean births, often due to patient preference or convenience, can contribute to the overall high rates of cesarean births.
A: Fetuses in breech position unable to deliver vaginally - This is a valid reason for cesarean births, but it does not address the question about high rates of cesarean births.
C: Incidences of women of older maternal age getting pregnant - While advanced maternal age can be a factor in cesarean births, it is not directly related to the high rates of cesarean births at the facility.
D: Decreasing rate of malpractice litigation with cesarean birth - This is an irrelevant factor in determining the reasons for high rates of cesarean births at the facility.
The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing
- A. a worsening hypoxi
- B. progressive acidosis.
- C. an expected respons
- D. parasympathetic stimulation.
Correct Answer: C
Rationale: The correct answer is C. After vibroacoustic stimulation, an increase in fetal heart rate baseline indicates an expected response, showing the fetus is healthy and responding appropriately to the stimulus. This increase is a sign of fetal well-being and does not suggest worsening hypoxia (choice A) or progressive acidosis (choice B). Additionally, parasympathetic stimulation (choice D) would typically lead to a decrease in heart rate, not an increase as observed in this scenario. Therefore, choice C is the best interpretation based on the positive response of the fetal heart rate to the stimulation, indicating a healthy and expected reaction.
The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings?
- A. Late decelerations
- B. Early decelerations
- C. Variable decelerations
- D. Proximal decelerations
Correct Answer: B
Rationale: The correct answer is B: Early decelerations. Early decelerations occur in response to fetal head compression during contractions, resulting in a gradual decrease in the fetal heart rate that mirrors the timing of contractions. In this scenario, the fetal heart rate drops to 20 bpm below the baseline during contractions and returns to baseline after contractions, indicating a benign pattern. Late decelerations (choice A) occur after the peak of the contraction and are associated with uteroplacental insufficiency. Variable decelerations (choice C) are abrupt decreases in fetal heart rate without a consistent timing in relation to contractions, often due to cord compression. Proximal decelerations (choice D) are not a recognized classification of decelerations in fetal monitoring.
A nurse is taking a birth history assessment on a client who is 8 weeks gestation and has one child who was born at 38 weeks. Which is consistent with this birth history?
- A. Primipara
- B. Primigravida
- C. Nulligravida
- D. Multipara
Correct Answer: D
Rationale: The correct answer is D: Multipara. This term refers to a woman who has given birth to two or more children. In this case, the client has one child already, making her a multipara.
A: Primipara refers to a woman who has given birth to one child, which does not match the client's birth history.
B: Primigravida refers to a woman who is pregnant for the first time, which also does not match the client's history.
C: Nulligravida refers to a woman who has never been pregnant, which is not the case for the client.
Therefore, the correct term to describe the client's birth history is Multipara, as she has one child and is currently 8 weeks gestation.
An emergency cesarean is being implemented. The patient describes tingling in her ears and a metallic taste with the administration of regional anesthesia. The nurse is aware that which incidence has occurred?
- A. Manifestation of maternal respiratory depression related to anesthesia
- B. Inadvertent injection of the anesthetic agent into the maternal bloodstream
- C. Maternal hypotension is occurring related to administration of anesthesia
- D. Expected manifestations related to anesthetic medications are present
Correct Answer: B
Rationale: The correct answer is B: Inadvertent injection of the anesthetic agent into the maternal bloodstream. This is indicated by the patient experiencing tingling in her ears and a metallic taste, which are signs of systemic toxicity from the anesthetic agent. The anesthetic has entered the bloodstream instead of staying localized to the intended area. Other choices are incorrect as A is more related to opioid overdose, C is more related to hypotension, and D implies that these symptoms are normal when they are not.