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When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated?
- A. Reposition the patient.
- B. Apply a fetal scalp electrode.
- C. Record this normal pattern.
- D. Administer oxygen by nasal cannula.
Correct Answer: C
Rationale: Rationale for correct answer (C): Recording the normal pattern is indicated because the deceleration pattern mirroring uterine contractions is a reassuring sign of fetal well-being. It indicates a physiologic response to labor. Repositioning the patient (A) is unnecessary as the pattern is normal. Applying a fetal scalp electrode (B) is invasive and unnecessary in this scenario. Administering oxygen (D) is not indicated as the fetal heart rate pattern is normal.
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The nurse will monitor for aspiration, thought processes, and improved mobility after which complication?
- A. neurologic dysfunction
- B. Measure blood loss.
- C. gestational diabetes
- D. postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: postpartum hemorrhage. The nurse monitors for aspiration due to potential bleeding or clotting issues postpartum. Monitoring thought processes is important as postpartum hemorrhage can lead to hypovolemic shock affecting cognition. Improved mobility is assessed as excessive bleeding can cause weakness. Neurologic dysfunction (choice A) is not directly related to postpartum hemorrhage. Measuring blood loss (choice B) is important but not the primary focus after postpartum hemorrhage. Gestational diabetes (choice C) is a separate condition unrelated to postpartum hemorrhage.
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.
Which of the following is theN pUriRorSitIy NinGteTrvBen.tiConO fMor the patient in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction?
- A. Administer O at 8 to 10 L/minut
- B. Decrease the IV rate to 100 mL/hour.
- C. Reposition the ultrasound transducer.
- D. Perform a vaginal exam to assess for cord prolaps
Correct Answer: A
Rationale: The correct answer is A: Administer O at 8 to 10 L/minut. In a left side-lying position, this deceleration indicates possible umbilical cord compression, reducing oxygen supply to the fetus. Administering oxygen at 8 to 10 L/min can help improve fetal oxygenation. Decreasing the IV rate (B) wouldn't directly address the fetal distress. Repositioning the ultrasound transducer (C) is irrelevant to the situation. Performing a vaginal exam (D) could worsen the cord compression if the cord is prolapsed.
A woman comes to the prenatal clinic because she thinks she is pregnant. Which of the following are probable signs of pregnancy? Select all that apply.
- A. Amenorrhea
- B. Uterine enlargement
- C. Positive pregnancy test
- D. Breast tenderness
Correct Answer: C
Rationale: The correct answer is C, positive pregnancy test. This is a probable sign of pregnancy because it directly indicates the presence of the pregnancy hormone hCG in the woman's body. Amenorrhea (choice A) and uterine enlargement (choice B) are actually presumptive signs of pregnancy, as they can be caused by factors other than pregnancy. Breast tenderness (choice D) is a possible sign of pregnancy but is not as specific or conclusive as a positive pregnancy test.
The nurse is providing care in PACU for a patient who just delivered a neonate via cesarean section. The patient reports tightness in her chest. Assessment findings include tachypnea, hypotension, and decreasing oxygen saturation levels. Which complication does the nurse report to the health care provider?
- A. Pulmonary embolism
- B. Postpartum hemorrhage
- C. Surgical-site infection
- D. Developing endometritis
Correct Answer: A
Rationale: The correct answer is A: Pulmonary embolism. The patient's symptoms of chest tightness, tachypnea, hypotension, and decreasing oxygen saturation levels are indicative of a potential pulmonary embolism, which is a serious complication post-cesarean section. A pulmonary embolism occurs when a blood clot travels to the lungs, causing respiratory distress and cardiovascular compromise. The nurse should report this immediately to the healthcare provider for prompt intervention to prevent further complications.
Incorrect choices:
B: Postpartum hemorrhage - Symptoms of postpartum hemorrhage include excessive bleeding, not chest tightness and respiratory distress.
C: Surgical-site infection - Symptoms of surgical-site infection include redness, swelling, and drainage at the incision site, not chest tightness and respiratory distress.
D: Developing endometritis - Symptoms of endometritis include fever, pelvic pain, and abnormal vaginal discharge, not chest tightness and respiratory distress.