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Which clinical finding would be an indication to the nurse that the fetus may be compromised?
- A. Active fetal movements
- B. Fetal heart rate in the 140s
- C. Contractions lasting 90 seconds
- D. Meconium-stained amniotic fluid
Correct Answer: D
Rationale: The correct answer is D. Meconium-stained amniotic fluid indicates fetal distress due to possible hypoxia. Meconium in the fluid can lead to meconium aspiration syndrome, a serious condition. The other choices are incorrect because active fetal movements (A) and a fetal heart rate in the 140s (B) are normal signs of fetal well-being. Contractions lasting 90 seconds (C) could indicate labor progress but do not necessarily indicate fetal compromise.
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Which patient will be most receptive to teaching about nonpharmacologic pain control methods?
- A. Gravida 1, para 0, in transition
- B. Gravida 2, para 1, admitted at 8 cm
- C. Gravida 1, para 0, dilated 2 cm, 80% effaced
- D. Gravida 3, para 2, complaining of intense perineal pressure
Correct Answer: C
Rationale: The correct answer is C because the patient is dilated at 2 cm and 80% effaced, indicating early labor. This stage allows for the patient to be receptive to learning about nonpharmacologic pain control methods. The other choices are incorrect because they are in active labor or experiencing intense pressure, making it less ideal for teaching nonpharmacologic methods.
The nurse is preparing a patient for a cesarean birth scheduled to be performed under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?
- A. Citric acid (Bicitra)
- B. Ranitidine (Zantac)
- C. Hydroxyzine (Vistaril)
- D. Glycopyrrolate (Robinul)
Correct Answer: C
Rationale: The correct answer is C: Hydroxyzine (Vistaril). Hydroxyzine is a first-generation antihistamine with antiemetic properties that can help reduce the risk of aspiration of gastric contents during general anesthesia. It works by decreasing nausea and vomiting, which in turn decreases the likelihood of aspiration. Citric acid (Bicitra) can actually increase gastric acidity and promote aspiration. Ranitidine (Zantac) is a histamine-2 receptor antagonist used to reduce gastric acid secretion but does not directly prevent aspiration. Glycopyrrolate (Robinul) is an anticholinergic medication used to reduce secretions but does not specifically target prevention of aspiration. Therefore, hydroxyzine is the most appropriate choice in this scenario.
What is a side effect of general anesthesia that usually limits its use to cases of emergency?
- A. hyperactive newborns
- B. newborn respiratory depression
- C. increase in uterine contractions
- D. decrease in cervical dilation
Correct Answer: B
Rationale: The correct answer is B: newborn respiratory depression. General anesthesia can cross the placental barrier and affect the newborn's respiratory system, leading to potential complications such as respiratory depression. This side effect is a major concern, especially in non-emergency situations, as it can pose risks to the newborn's health. Hyperactive newborns (A), increase in uterine contractions (C), and decrease in cervical dilation (D) are not typical side effects of general anesthesia that limit its use in emergency cases. These options are unrelated to the primary concern of newborn respiratory depression in the context of administering general anesthesia during childbirth.
When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.)
- A. Check the DTR each shift.
- B. Monitor and record vital signs frequently during the course of labor.
- C. Document the FHR pattern, noting baseline and response to contraction patterns.
- D. Indicate on the EFM tracing when maternal position changes are don
Correct Answer: B
Rationale: The correct answer is B: Monitor and record vital signs frequently during the course of labor. This is essential to ensure the patient's physiological stability and detect any deviations that may indicate complications. Checking the DTR (Choice A) is not relevant for low-risk patients in labor. Documenting the FHR pattern (Choice C) is important, but not as crucial as monitoring vital signs. Indicating maternal position changes on the EFM tracing (Choice D) is beneficial but not a priority assessment for low-risk patients. Vital sign monitoring is the most critical assessment for ensuring the well-being of the patient in labor.
Which nursing action is most appropriate for a laboring patient experiencing severe back pain due to a posterior fetal position?
- A. Offer narcotic analgesics for pain relief.
- B. Encourage frequent position changes.
- C. Provide continuous fetal monitoring.
- D. Prepare the patient for an immediate cesarean delivery.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent position changes. This is because changing positions can help alleviate pressure on the back and potentially help the baby rotate into a more favorable position for delivery. It is a non-invasive and supportive approach to managing back pain during labor. Offering narcotic analgesics (choice A) may provide temporary relief but does not address the underlying issue. Continuous fetal monitoring (choice C) is important but not the most immediate intervention for back pain. Immediately preparing for a cesarean delivery (choice D) is not warranted unless there are other concerning factors beyond back pain.