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 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.
Correct Answer is A
Explanation
Choice A rationale:
An Apgar score of 10 at 1 minute after birth indicates that the infant is in excellent condition, adjusting well to extrauterine life, and requires no further testing or interventions at that moment. The Apgar score assesses the baby's heart rate, respiratory effort, muscle tone, reflexes, and color, with a maximum score of 10. An Apgar score of 10 suggests that the baby is pink, has a heart rate above 100 beats per minute, exhibits strong cries, has active motion, and demonstrates good muscle tone.
Choice B rationale:
An Apgar score of 10 does not indicate severe distress requiring resuscitation. A low Apgar score (typically below 7) at 1 minute may prompt further evaluation and interventions to support the baby's transition to extrauterine life.
Choice C rationale:
While a high Apgar score is reassuring, it does not predict a future free of neurologic problems. The Apgar score assesses the baby's current condition and provides a snapshot of their overall well-being at birth.
Choice D rationale:
Although the Apgar score is assessed at 1 and 5 minutes after birth, a score of 10 at 1 minute suggests that the baby is doing well at that moment. However, the baby should still be assessed again at 5 minutes to ensure continued stability and appropriate interventions if necessary.
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