Nokea
What nursing assessment should be reported immediately after an amniotomy?
- A. Fetal heart rate is regular at 154 beats/minute.
- B. Amniotic fluid is clear with flecks of vernix.
- C. Amniotic fluid is watery and pale green.
- D. Maternal temperature is 37.8?°C.
Correct Answer: C
Rationale: Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.
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When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block?
- A. Abnormal clotting
- B. Previous cesarean delivery
- C. History of migraine headaches
- D. History of diabetes mellitus
Correct Answer: A
Rationale: An epidural block is not used if a woman has abnormal blood clotting.
A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block?
- A. I'm having a contraction. Can I get the pudendal block now?'
- B. I'll get the pudendal block right before I deliver.'
- C. The nurse-midwife will insert the needles into my vagina.'
- D. It takes a few minutes after the medicine is administered to make me feel numb.'
Correct Answer: A
Rationale: The pudendal block does not block pain from contractions and is given just before birth.
A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction?
- A. Use slow-paced breathing.
- B. Hold her breath and push.
- C. Blow in short breaths.
- D. Use rapid-paced breathing.
Correct Answer: C
Rationale: If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down.
What is the most appropriate nursing action to take when a laboring woman hyperventilates?
- A. Help her breathe into her cupped hands.
- B. Place her flat on her back.
- C. Initiate oxygen at 2 liters via mask.
- D. Notify the doctor.
Correct Answer: A
Rationale: Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.
What is the least amount of sensation that one perceives as pain?
- A. Tolerance
- B. Threshold
- C. Level
- D. Abatement
Correct Answer: B
Rationale: Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.