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:
Limiting the time spent on exploration of intimate topics may result in incomplete information, leading to potential gaps in the patient's health history. It's essential to create a safe and supportive environment, allowing the patient to share necessary information freely.
Choice B rationale:
Avoiding questions that may embarrass the patient could prevent the nurse from gathering crucial information related to the patient's reproductive health. Sensitivity and non-judgmental communication are essential, enabling the patient to openly discuss sensitive topics.
Choice C rationale:
Using accepted medical terminology is important, but it should be balanced with clear communication. Complex medical terms might confuse the patient. It's essential to use language that the patient can understand, ensuring effective communication and a better understanding of their health.
Choice D rationale:
This statement indicates a correct understanding of the best approach when obtaining a reproductive health history. Explaining the purpose for the questions asked and how the information will be used builds trust and helps the patient feel more comfortable sharing sensitive information. It also ensures that the patient understands the relevance of the questions, fostering open communication between the patient and the healthcare provider.
Correct Answer is C
Explanation
Choice A rationale:
Ribbon-like stools are not characteristic of intussusception. Intussusception is a medical emergency where one portion of the intestine invaginates or telescopes into another. This condition can lead to intestinal obstruction and compromised blood flow, causing severe abdominal pain, vomiting, and bloody stools. The characteristic stool appearance associated with intussusception is "currant jelly" stools. These stools contain mucus, blood, and sloughed mucosal tissue, giving them a characteristic dark, sticky, and jelly-like appearance. This occurs due to the mixture of blood and mucus within the intestines.
Choice B rationale:
Hard stools positive for guaiac indicate the presence of occult blood in the stool, but this finding is not specific to intussusception. Occult blood in the stool can be a sign of gastrointestinal bleeding from various causes, such as ulcers, gastritis, or colorectal polyps. It is not a characteristic feature of intussusception.
Choice D rationale:
Loose, foul-smelling stools are nonspecific and can occur due to various gastrointestinal disorders, dietary issues, or infections. This description does not specifically indicate intussusception.
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