Nokea
When a pattern of variable decelerations occur, the nurse should immediately
- A. administer O at 8 to 10 L/minut
- B. place a wedge under the right hip.
- C. increase the IV fluids to 150 mL/hour.
- D. position patient in a knee-chest position.
Correct Answer: D
Rationale: The correct answer is D because positioning the patient in a knee-chest position helps to relieve pressure on the vena cava, improving blood flow to the placenta and fetus. This can help alleviate variable decelerations. Choice A is incorrect because administering oxygen at 8 to 10 L/min would not directly address the cause of variable decelerations. Choice B is incorrect as placing a wedge under the right hip is typically used for supine hypotension syndrome. Choice C is incorrect because increasing IV fluids may not directly address the issue of variable decelerations.
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What is a condition in which there is an excessive amount of amniotic fluid surrounding the fetus?
- A. amniotic fluid embolism
- B. gestational diabetes
- C. oligohydramnios
- D. polyhydramnios
Correct Answer: D
Rationale: The correct answer is D: polyhydramnios. Polyhydramnios is a condition characterized by an excessive amount of amniotic fluid surrounding the fetus. This can occur due to various reasons such as fetal malformations, multiple gestations, or maternal diabetes. The excess fluid can lead to complications such as preterm labor or fetal malpresentation.
A: Amniotic fluid embolism is a rare and life-threatening condition where amniotic fluid enters the maternal bloodstream, causing an allergic reaction.
B: Gestational diabetes is a condition where high blood sugar levels develop during pregnancy, but it is not directly related to the amount of amniotic fluid.
C: Oligohydramnios is the opposite of polyhydramnios, characterized by a deficiency of amniotic fluid, which can also lead to complications.
The nurse is monitoring a patient who has been in prolonged labor. Which assessment finding will result in the nurse notifying the health care provider about the development of an emergent situation requiring a cesarean delivery?
- A. Maternal blood pressure indicative of hypotension
- B. Maternal exhaustion from prolonged uterine activity
- C. Recognition of a Category II fetal heart rate pattern
- D. Increased maternal temperature related to infection
Correct Answer: C
Rationale: The correct answer is C: Recognition of a Category II fetal heart rate pattern. This indicates fetal distress and potential compromise to the baby's well-being, necessitating immediate intervention like a cesarean delivery to prevent adverse outcomes. A: Maternal hypotension may require intervention but is not an emergent indication for a cesarean section. B: Maternal exhaustion can be managed with support and rest, not an immediate indication for cesarean delivery. D: Maternal fever may indicate infection but does not necessarily require cesarean delivery unless it poses a significant risk to the baby.
A primigravida patient asks the nurse to explain the term quickening. Which statement by the nurse is correct?
- A. It is intermittent uterine contractions caused by the increase in hormones, especially estrogen.
- B. It is the absence of menses and is one of the earliest symptoms a woman reports when she is pregnant.
- C. It is when the mother can first feel the movements of the fetus.
- D. It is an increase in vaginal discharge caused by the increase in estrogen.
Correct Answer: C
Rationale: The correct answer is C because quickening refers to the first time a mother feels fetal movements, usually around 18-20 weeks gestation. This marks the beginning of fetal movements that the mother can perceive.
A is incorrect because intermittent uterine contractions are not referred to as quickening.
B is incorrect as it describes amenorrhea, not quickening.
D is incorrect as an increase in vaginal discharge is not the definition of quickening.
The placenta is diagnosed as retained when it is not delivered in what timeframe after the birth of the infant?
- A. 10 minutes
- B. 30 minutes
- C. 1 hour
- D. 2 hours
Correct Answer: B
Rationale: The correct answer is B (30 minutes) because the placenta should be delivered within 30 minutes after the birth of the infant to prevent excessive bleeding and potential complications. If the placenta is retained beyond 30 minutes, it may lead to postpartum hemorrhage. Choices A, C, and D are incorrect as they do not align with the standard timeframe for the delivery of the placenta. A (10 minutes) is too soon for a normal delivery, C (1 hour) is too long and increases the risk of complications, and D (2 hours) is significantly delayed and poses serious health risks.
The nurse in the post-delivery unit is encouraging skin-to-skin contact for a mother and neonate after cesarean delivery. Which action, if noticed by the nurse, requires immediate intervention by the nurse?
- A. Mother is sitting up with the neonate prone on her chest.
- B. Mother is supine with the neonate prone on her chest.
- C. The neonate is prone on mother’s chest and facing to the side.
- D. Neonate is prone with mother resting in semi-Fowler’s position.
Correct Answer: B
Rationale: B is the correct answer because having the mother in a supine position with the neonate prone on her chest can potentially increase the risk of neonatal suffocation or accidental injury due to the baby slipping off. This position restricts the baby's ability to breathe properly and may lead to adverse outcomes.
A: Sitting up with the neonate prone on her chest allows for better supervision and support for the baby's breathing.
C: The neonate facing to the side is a safe position for skin-to-skin contact and breastfeeding.
D: Neonate resting in semi-Fowler's position is a safe and comfortable position that allows for proper breathing and bonding between mother and baby.