Nokea
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.
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What is the cause?
- A. Prolonged pressure against the partially dilated cervix
- B. Small leak of fluid through the posterior fontanelle
- C. Pressure of the forceps during delivery
- D. The effect of the vacuum extractor
Correct Answer: D
Rationale: The 'chignon' is due to the effect of the vacuum extractor and will disappear in a few days.
What is the most appropriate nursing diagnosis?
- A. Anxiety related to the development of postpartum complications
- B. Ineffective individual coping related to unfamiliarity with procedures
- C. Risk for ineffective parenting related to emergency cesarean section
- D. Grieving related to loss of expected birth experience
Correct Answer: D
Rationale: Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger, because the expected course of birth did not occur.
What is the best nursing action?
- A. Give the pain remedy.
- B. Notify the charge nurse immediately.
- C. Turn the patient to her back and flex her knees.
- D. Suggest that the coach give her a back rub.
Correct Answer: B
Rationale: Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.
What complications of overstimulation of uterine contractions may occur?
- A. Water intoxication
- B. Impaired placental exchange of oxygen and nutrients
- C. Increased blood pressure
- D. Convulsions
- E. Uterine rupture
Correct Answer: A,B,E
Rationale: The most common complications are impaired placental exchange, uterine rupture, and water intoxication due to fluid retention.
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.