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What is the priority nursing action when a nurse suspects a cord prolapse during labor?
- A. place the person in the knee-chest position
- B. administer oxygen via mask
- C. apply pressure to the cord
- D. administer an epidural
Correct Answer: A
Rationale: The correct answer is A: place the person in the knee-chest position. This is the priority nursing action because it helps relieve pressure on the cord and prevents further prolapse. Placing the person in the knee-chest position also promotes optimal fetal oxygenation. Administering oxygen via mask (choice B) is important but not the priority. Applying pressure to the cord (choice C) should never be done as it can further compromise blood flow to the fetus. Administering an epidural (choice D) is not the priority in this emergency situation.
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The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
- A. Repeat the test in 1 week so that results can be trended based on this baseline result.
- B. Contact the health care provider to discuss birth options for the patient.
- C. Send the patient out for a meal and repeat the test to confirm that the results are valid.
- D. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.
Correct Answer: B
Rationale: A positive CST is an abnormal finding that may indicate fetal compromise, requiring immediate discussion of birth options.
A patient in labor is diagnosed with an occiput posterior (OP) fetal position. What is the most appropriate intervention to facilitate delivery?
- A. Encourage the patient to push vigorously with each contraction
- B. Position the patient on her hands and knees
- C. Perform a cesarean section
- D. Perform a cesarean section
Correct Answer: B
Rationale: The correct answer is B: Position the patient on her hands and knees. This position, known as the all-fours position, can help rotate the baby from an occiput posterior position to a more favorable position for delivery. Gravity assists in the rotation of the baby, making delivery easier. Encouraging the patient to push vigorously (option A) may not be effective in this situation as the baby may be facing the wrong way. Performing a cesarean section (option C and D) should be considered only if other interventions fail or if there are complications that necessitate surgical delivery.
What change occurs at the same time as quickening?
- A. Fetal heart begins to beat
- B. Lanugo covers the body
- C. Kidneys secrete urine
- D. Fingernails begin to form
Correct Answer: C
Rationale: Quickening typically coincides with the onset of fetal kidney function and urine secretion.
A nurse is caring for a postpartum person who is at risk for uterine atony. What is the priority intervention to prevent uterine atony?
- A. administer uterotonic medication
- B. administer an analgesic
- C. perform uterine massage
- D. administer IV fluids
Correct Answer: B
Rationale: The correct answer is B: administer an analgesic. This is the priority intervention because pain management helps the person relax, which reduces stress on the uterus and promotes effective contraction to prevent uterine atony. Administering uterotonic medication (choice A) may help contract the uterus but addressing pain first is crucial. Performing uterine massage (choice C) can assist in contracting the uterus but is not the priority intervention. Administering IV fluids (choice D) is important for hydration but does not directly address preventing uterine atony.
What change occurs at the same time as quickening?
- A. Fetal heart begins to beat
- B. Lanugo covers the body
- C. Kidneys secrete urine
- D. Fingernails begin to form
Correct Answer: C
Rationale: Quickening typically coincides with the onset of fetal kidney function and urine secretion.