A laboring woman is lying in the supine position.
The most appropriate nursing action at this time is to:.
Ask her to turn to one side.
Elevate her feet and legs.
Take her blood pressure.
Determine whether fetal tachycardia is present.
The Correct Answer is A
Choice A rationale:
Ask her to turn to one side. The supine position during labor can compress the vena cava, reducing blood flow to the uterus and potentially compromising fetal oxygenation. Turning the woman to her side, especially the left side, can relieve this pressure and improve blood flow to the uterus, ensuring adequate oxygen supply to the fetus. This position change is crucial for the well-being of both the mother and the baby during labor.
Choice B rationale:
Elevate her feet and legs. Elevating the woman's feet and legs might not be effective in relieving the pressure on the vena cava, as it does not change the orientation of the uterus in relation to the vena cava. Turning the woman to her side is a more appropriate and effective action to improve blood flow to the uterus and fetus.
Choice C rationale:
Take her blood pressure. While monitoring the woman's blood pressure is essential during labor, it is not the most appropriate action in this situation. The priority is to relieve the compression of the vena cava by changing the woman's position.
Choice D rationale:
Determine whether fetal tachycardia is present. Monitoring the fetal heart rate is crucial during labor, but the woman's position should be the immediate concern if she is lying in the supine position. Changing her position to relieve the vena cava compression takes precedence to ensure adequate oxygenation to the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Perinatal transmission of HIV can occur not only in the third trimester but also during labor and delivery. It is not limited to the maternal circulation alone.
Choice B rationale:
While needlestick injuries are a potential risk for healthcare workers, perinatal transmission to the newborn does not occur through this route.
Choice C rationale:
HIV is not transmitted through the ingestion of amniotic fluid. The virus can be present in the amniotic fluid, but the main route of transmission to the newborn is during delivery or through breastfeeding.
Choice D rationale:
The correct answer. HIV can be transmitted from an infected mother to her child through breastfeeding if appropriate antiretroviral therapy is not administered. Breast milk can contain the virus, putting the infant at risk of infection. Therefore, in cases where the mother is HIV-positive, formula feeding is recommended to prevent transmission of the virus to the newborn.
Correct Answer is C
Explanation
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The correct answer is choice C. Visible peristalsis and weight loss.
Choice A rationale:
Abdominal rigidity and pain on palpation are not typically indicative of pyloric stenosis. These symptoms could be associated with a variety of other gastrointestinal conditions.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are not specific to pyloric stenosis. These symptoms could be seen in various gastrointestinal disorders.
Choice C rationale:
Visible peristalsis and weight loss are classic symptoms of pyloric stenosis. The condition causes a narrowing of the opening from the stomach to the small intestine, preventing food from passing through. This leads to vomiting after feeding, persistent hunger, and weight loss since very little food passes to the small intestines.
Choice D rationale:
Distention of the lower abdomen and constipation are not typically indicative of pyloric stenosis. These symptoms could be associated with a variety of other gastrointestinal conditions.
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