Nokea
What will the nurse expect when caring for this patient?
- A. Elevated uterine resting tone
- B. Painful and poorly coordinated contractions
- C. Implementation of fluid restriction
- D. Use of frequent position changes
Correct Answer: D
Rationale: A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions.
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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.
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 purpose of glucocorticoid administration?
- A. Prevent infection.
- B. Increase fetal lung maturity.
- C. Increase blood flow from placenta.
- D. Relax the cervix.
Correct Answer: B
Rationale: Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.
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 action by the physician will the nurse anticipate?
- A. Perform an amniotomy.
- B. Initiate tocolytic drugs.
- C. Order a sedative for the patient.
- D. Plan to do an emergency cesarean section.
Correct Answer: A
Rationale: Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact.