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What is the priority intervention for a laboring person with a suspected uterine rupture?
- A. prepare for an emergency cesarean section
- B. perform uterine massage
- C. apply pressure to the abdomen
- D. monitor the fetal heart rate continuously
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation.
Incorrect choices:
A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial.
C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications.
D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.
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A 38-week pregnant patient in active labor is experiencing frequent and painful contractions. What is the most appropriate action for the nurse?
- A. Administer narcotic analgesics for pain relief
- B. Provide emotional support and reassurance
- C. Assess the fetal heart rate and contraction patterns
- D. Prepare for delivery
Correct Answer: D
Rationale: The correct answer is D: Prepare for delivery. At 38 weeks of gestation and in active labor, the most appropriate action is to prepare for delivery as the patient is likely to be close to giving birth. This involves ensuring that all necessary equipment and supplies are ready, notifying the healthcare team, and positioning the patient for delivery. Administering narcotic analgesics (choice A) may not be ideal at this stage as the priority is the imminent delivery. While emotional support and reassurance (choice B) are important, they should be provided alongside preparing for delivery. Assessing the fetal heart rate and contraction patterns (choice C) is crucial but should be done concurrently with preparing for delivery to ensure the safety of both the mother and baby.
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head crowns?
- A. apply gentle downward pressure
- B. assist with shoulder delivery
- C. assist with perineal massage
- D. administer pain relief
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of perineal tearing and ensuring a controlled birth. Applying too much pressure can cause trauma to the mother and baby. Incorrect choices: B is premature, as shoulder delivery should only be done after the head and shoulders are delivered. C is not the most important action at crowning. D is not necessary at this specific stage of delivery.
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 nurse is educating a pregnant patient who is at 30 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is safe and beneficial for pregnant women at 30 weeks gestation. Moderate exercise helps maintain health, improves circulation, reduces stress, and prepares the body for labor. Strenuous exercise (A) can be risky and may lead to complications. Avoiding all physical activity (C) can result in deconditioning and potential complications. High-impact exercises (D) can be too intense and pose a risk of injury during pregnancy. Prioritizing moderate exercise aligns with current guidelines for safe physical activity during pregnancy.
A nurse is caring for a postpartum person who is experiencing a boggy uterus. What is the priority intervention?
- A. perform uterine massage
- B. encourage early ambulation
- C. assist with positioning
- D. perform a pelvic exam
Correct Answer: A
Rationale: The correct answer is A: perform uterine massage. This is the priority intervention for a boggy uterus to prevent postpartum hemorrhage by promoting uterine contraction and reducing bleeding. Uterine massage helps the uterus to firm up and expel clots. Early ambulation (B) and positioning (C) can support recovery but do not directly address the boggy uterus. Performing a pelvic exam (D) is not necessary for managing a boggy uterus and may even exacerbate bleeding.