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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What position will the nurse promote to encourage fetal rotation and pain relief?
- A. Prone with legs supported and give her a back massage
- B. Supine with legs bent at the knee
- C. Standing with support
- D. Sitting up and leaning forward on the overbed table
Correct Answer: D
Rationale: A position that favors fetal rotation and descent and is helpful for the woman with back labor is to sit or kneel leaning forward on a support.
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 will the nurse include in the educational plan?
- A. Onset is slow.
- B. Duration is short.
- C. Administration is by mouth.
- D. No known side effects.
- E. It is not the same drug as sufentanil.
Correct Answer: B,E
Rationale: Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are distinct drugs. Fentanyl can cause respiratory depression but less than meperidine and is not administered by mouth.
What should the nurse assess for in the newborn?
- A. Loss of hair from contact with forceps
- B. Sacral hematoma
- C. Facial asymmetry
- D. Shoulder dislocation
Correct Answer: C
Rationale: Pressure from forceps may injure the infant's facial nerve, which is evidenced by facial asymmetry.
What is the lowest Bishop score the patient should have prior to induction?
- A. 6
- B. 8
- C. 10
- D. 12
Correct Answer: A
Rationale: The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American College of Obstetricians and Gynecologists (ACOG).