Nokea
What is this labor pattern considered?
- A. Normal
- B. Hypotonic
- C. Hypertonic
- D. FALSE
Correct Answer: B
Rationale: The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.
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What is the best response?
- A. The fundus is not assessed until the second postoperative day.
- B. The fundus is assessed by 'walking' fingers from the side of the uterus to the midline.
- C. The fundus is assessed only if large clots appear in lochia.
- D. The fundus is assessed only once every shift.
Correct Answer: B
Rationale: Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.
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 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 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.
How would the nurse position the woman to prevent compression of a prolapsed cord?
- A. On her right side with knees flexed
- B. On her left side with a pillow placed between her legs
- C. On her back with her head lower than the rest of her body
- D. Supine with her legs elevated and bent at the knee
Correct Answer: C
Rationale: The Trendelenburg's (head down) position displaces the fetus upward to stop compression of the prolapsed cord.