Nokea
Which statement correctly describes the nurse's responsibility related to electronic monitoring?
- A. Report abnormal findings to the physician before initiating corrective actions.
- B. Teach the woman and her support person about the monitoring equipment and discuss any of their questions.
- C. Document the frequency, duration, and intensity of contractions measured by the
- D. Inform the support person that the nurse will be responsible for all comfort
Correct Answer: B
Rationale: The correct answer is B because it aligns with the nurse's responsibility to educate and provide information to the patient and their support person. Teaching about the monitoring equipment and addressing any questions ensures that the patient and their support person are informed and empowered. This promotes patient understanding and involvement in their care, leading to better outcomes.
Choice A is incorrect because the nurse should initiate corrective actions promptly for abnormal findings without waiting for physician input. Choice C is incorrect as it focuses solely on documentation rather than patient education. Choice D is incorrect as it neglects the importance of involving the support person in the care process.
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What intervention may be used to manage failure to descend during labor?
- A. administering pain medication
- B. allowing the patient to rest
- C. continuing to push for an extended period of time
- D. using forceps or a vacuum to assist delivery
Correct Answer: D
Rationale: The correct answer is D because using forceps or a vacuum to assist delivery can help manage failure to descend during labor by aiding in the descent of the baby through the birth canal. Forceps or vacuum extraction can provide the necessary assistance to safely deliver the baby when maternal pushing alone is insufficient.
Explanation for why the other choices are incorrect:
A: Administering pain medication does not address the underlying issue of failure to descend during labor.
B: Allowing the patient to rest may not resolve the issue of failure to descend and could potentially delay necessary interventions.
C: Continuing to push for an extended period of time without progress can lead to maternal exhaustion and fetal distress without addressing the root cause of failure to descend.
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.
What nursing intervention is performed during labor for a person with preeclampsia?
- A. Assess deep tendon reflexes for hyperreflexia.
- B. Provide frequent IV fluid boluses.
- C. Educate the laboring person that preeclampsia is only a concern for pregnancy, not labor.
- D. Discourage pain medication in order to assess for headache.
Correct Answer: A
Rationale: The correct answer is A: Assess deep tendon reflexes for hyperreflexia. This is crucial in preeclampsia to monitor for signs of worsening condition like eclampsia. Hyperreflexia is a common symptom in severe preeclampsia indicating CNS irritability. Providing IV fluid boluses (B) can worsen fluid overload. Educating that preeclampsia is only a concern for pregnancy (C) is incorrect as it can progress during labor. Discouraging pain medication (D) is inappropriate as it can mask symptoms like headaches, a common sign of worsening preeclampsia.
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.
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.