Nokea
Which of the following is the most important nursing intervention for a laboring person who is receiving oxytocin for induction of labor?
- A. monitor for signs of uterine hyperstimulation
- B. monitor fetal heart rate continuously
- C. provide emotional support
- D. encourage ambulation
Correct Answer: B
Rationale: The correct answer is B: monitor fetal heart rate continuously. This is crucial because oxytocin can cause uterine hyperstimulation leading to fetal distress. Continuous monitoring allows for early detection of fetal compromise. Monitoring for signs of uterine hyperstimulation (A) is important but secondary to fetal well-being. Emotional support (C) and encouraging ambulation (D) are beneficial but not as critical as ensuring fetal safety during oxytocin administration.
You may also like to solve these questions
Which of the following is the most appropriate nursing action for a patient who has been administered an epidural block and is now experiencing hypotension?
- A. Administer a bolus of IV fluids
- B. Place the patient in a Trendelenburg position
- C. Administer oxygen via mask
- D. Raise the head of the bed slightly
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. Hypotension after an epidural block is often due to vasodilation caused by the block. Administering IV fluids can help increase blood volume and improve blood pressure. This action is crucial in maintaining perfusion to vital organs.
Choice B: Placing the patient in a Trendelenburg position can potentially worsen hypotension by increasing venous return to the heart, leading to further vasodilation and reduced blood pressure.
Choice C: Administering oxygen via mask may be important in some situations but is not the primary intervention for hypotension caused by epidural block.
Choice D: Raising the head of the bed slightly is not the best option for treating hypotension as it does not address the underlying cause of vasodilation and decreased blood pressure.
A client is in the 10th week of her pregnancy. Which of the following symptoms would the nurse expect the client to exhibit? Select all that apply.
- A. Backache.
- B. Urinary frequency.
- C. Dyspnea on exertion.
- D. Fatigue.
Correct Answer: A
Rationale: Backache, urinary frequency, and fatigue are common symptoms during the first trimester. Dyspnea on exertion is more common later in pregnancy.
The nurse is providing prenatal education to a pregnant patient about the signs of labor. Which of the following symptoms should the nurse instruct the patient to report immediately?
- A. Feeling pressure in the lower abdomen
- B. A bloody show or the loss of the mucous plug
- C. Regular contractions every 5 minutes for 1 hour
- D. A sudden increase in fetal movements
Correct Answer: C
Rationale: The correct answer is C: Regular contractions every 5 minutes for 1 hour. This is a sign of active labor and indicates that the patient should seek immediate medical attention. Contractions at this frequency and duration suggest that labor is progressing and the patient should go to the hospital. Choices A, B, and D are not indicative of active labor and do not require immediate medical attention. Feeling pressure in the lower abdomen may be a normal part of pregnancy. A bloody show or loss of the mucous plug can be early signs of labor but do not require immediate attention unless accompanied by other symptoms. A sudden increase in fetal movements is generally considered a positive sign of fetal well-being.
A nurse is caring for a patient in labor who is receiving oxytocin for induction. Which of the following is a priority assessment for the nurse?
- A. Fetal heart rate monitoring
- B. Fluid intake and output
- C. Uterine tone assessment
- D. Maternal blood pressure monitoring
Correct Answer: A
Rationale: The correct answer is A: Fetal heart rate monitoring. This is a priority assessment because oxytocin can cause uterine hyperstimulation, leading to fetal distress. Monitoring the fetal heart rate allows early detection of any signs of fetal compromise. Choices B, C, and D are important assessments but not the priority in this situation. Monitoring fluid intake and output, uterine tone, and maternal blood pressure are also crucial but do not directly assess fetal well-being, which is the primary concern during labor induction with oxytocin.
What is the priority intervention for a laboring person with a suspected uterine rupture?
- A. prepare for an emergency cesarean section
- B. perform uterine massage
- C. apply pressure to the abdomen
- D. monitor the fetal heart rate continuously
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation.
Incorrect choices:
A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial.
C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications.
D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.