Nokea
What nursing intervention is performed during labor for a person with preeclampsia?
- A. Assess deep tendon reflexes for hyperreflexia.
- B. Provide frequent IV fluid boluses.
- C. Educate the laboring person that preeclampsia is only a concern for pregnancy, not labor.
- D. Discourage pain medication in order to assess for headache.
Correct Answer: A
Rationale: The correct answer is A: Assess deep tendon reflexes for hyperreflexia. This is crucial in preeclampsia to monitor for signs of worsening condition like eclampsia. Hyperreflexia is a common symptom in severe preeclampsia indicating CNS irritability. Providing IV fluid boluses (B) can worsen fluid overload. Educating that preeclampsia is only a concern for pregnancy (C) is incorrect as it can progress during labor. Discouraging pain medication (D) is inappropriate as it can mask symptoms like headaches, a common sign of worsening preeclampsia.
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In preparation for a cesarean birth, the nurse expects which medical-based preoperative interventions? Select all that apply.
- A. Administration of narrow-spectrum prophylactic antibiotics
- B. Verification that the woman has been NPO for 6 to 8 hours before surgery
- C. Assessment of the woman’s knowledge and educational needs
- D. Assessment for risk of venous thromboembolism (VTE)
Correct Answer: B
Rationale: The correct answer is B because being NPO (nothing by mouth) for 6 to 8 hours before surgery helps prevent aspiration during anesthesia. Option A is incorrect because broad-spectrum antibiotics are typically used to cover a wider range of potential pathogens. Option C is not a medical-based preoperative intervention. Option D, while important, is more related to postoperative care rather than preoperative interventions.
With what has maternal hypertension been associated?
- A. anorexia
- B. low birth weight
- C. macrosomia
- D. symphysis pubis dysfunction
Correct Answer: B
Rationale: Maternal hypertension can lead to decreased blood flow to the placenta, resulting in restricted growth and low birth weight in the baby. This association is well-documented in research and clinical practice. Low birth weight is a common consequence of maternal hypertension due to inadequate nutrient and oxygen supply to the fetus. Therefore, choice B is the correct answer. Choices A, C, and D are not directly associated with maternal hypertension. Anorexia is a psychological disorder related to eating habits, macrosomia refers to excessive birth weight, and symphysis pubis dysfunction is a musculoskeletal issue during pregnancy.
The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation?
- A. This pattern reflects variable decelerations. No interventions are necessary at this time
- B. Document this Category I fetal heart rate pattern and decrease the rate of the
- C. Continue to monitor these early decelerations, which occur as the fetal head is
compressed during a contraction - D. This deceleration pattern is associated with uteroplacental insufficiency. The nurse
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. The deceleration pattern described, beginning near the acme of the contraction and extending beyond, is associated with uteroplacental insufficiency.
2. Uteroplacental insufficiency indicates a potential problem with oxygen and nutrient delivery to the fetus.
3. This situation requires immediate intervention to improve oxygenation to the fetus.
4. Monitoring alone is not sufficient; action is needed to address the underlying issue.
5. Therefore, the correct nursing action in this situation is to recognize the potential uteroplacental insufficiency and take appropriate measures to address it.
Summary of why other choices are incorrect:
A: This pattern reflects variable decelerations - Incorrect because the described pattern is not characteristic of variable decelerations.
B: Document this Category I fetal heart rate pattern and decrease the rate of the - Incorrect because immediate action is needed in the presence of potential uteroplacental insufficiency.
The nurse documents a prenatal patient’s GTPAL as G5T2P1A1L4. Which obstetric history is consistent with this assessment?
- A. The woman is currently pregnant, has five living children.
- B. The woman is currently pregnant and had two preterm pregnancies.
- C. The woman is not currently pregnant and has had one abortion.
- D. The woman is currently pregnant and had one set of twins.
Correct Answer: A
Rationale: Rationale:
1. G5 = Gravida 5 (woman has been pregnant 5 times)
2. T2 = Term births 2 (woman has had 2 full-term pregnancies)
3. P1 = Preterm births 1 (woman has had 1 preterm pregnancy)
4. A1 = Abortions 1 (woman has had 1 abortion)
5. L4 = Living children 4 (woman has 4 living children)
Summary:
- Choice A is correct as it aligns with the GTPAL components.
- Choice B is incorrect because it does not match the number of term and preterm births.
- Choice C is incorrect as it does not reflect the number of living children.
- Choice D is incorrect as it does not indicate any preterm pregnancies.
How soon should delivery of the fetus occur when a Category III FHR tracing is diagnosed?
- A. 15 minutes
- B. 30 minutes
- C. 45 minutes
- D. 60 minutes
Correct Answer: B
Rationale: The correct answer is B: 30 minutes. When a Category III FHR tracing is diagnosed, it indicates severe fetal distress. Prompt delivery is crucial to prevent adverse outcomes. 30 minutes allows for timely intervention without risking further harm to the fetus. Option A (15 minutes) may be too rushed, potentially causing unnecessary stress during the delivery process. Options C (45 minutes) and D (60 minutes) delay delivery, increasing the risk of complications due to prolonged fetal distress. Timing is critical in ensuring the best possible outcome for both the mother and the baby.