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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
Koplik's spots are small white or bluish-white spots with a red halo that appear inside the mouth on the buccal mucosa. They are a characteristic sign of measles (rubeola). Measles is a highly contagious viral infection characterized by fever, cough, runny nose, and a distinctive red rash. The presence of Koplik's spots is a specific diagnostic feature of measles, making choice A incorrect for this scenario.
Choice B rationale:
Koplik's spots are a classic sign of measles (rubeola). These spots typically appear a few days before the onset of the measles rash and are highly indicative of the disease. Measles is a highly contagious viral infection that spreads through respiratory droplets. It is essential to recognize Koplik's spots as they provide an early clue to the diagnosis of measles, enabling healthcare providers to take appropriate precautions and prevent the further spread of the disease.
Choice C rationale:
Chickenpox (varicella) presents with an itchy rash that progresses to fluid-filled blisters. However, Koplik's spots are not associated with chickenpox. Chickenpox is caused by the varicella-zoster virus and is characterized by a widespread rash, fever, and general discomfort. Koplik's spots are specific to measles and do not occur in chickenpox.
Choice D rationale:
Exanthema subitum, also known as roseola, is a viral illness that primarily affects infants and young children. It is characterized by high fever followed by a rash. However, Koplik's spots are not a feature of roseola. The rash in roseola appears after the fever subsides and is typically pink or red, differentiating it from the small white spots seen in measles.

A. apply an oil-based lotion to the newborn's skin to prevent drying and cracking. B. limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. C. place eye shields over the newborn's closed eyes. D. change the newborn's position every 4 hours.

Correct Answer is C

Explanation

Choice A rationale:

Applying oil-based lotion is not recommended during phototherapy as it can block the pores and reduce the effectiveness of the therapy. The baby's skin should be exposed to the light as much as possible to treat hyperbilirubinemia effectively.

Choice B rationale:

Limiting the newborn's intake of milk is not appropriate. Adequate hydration and nutrition are essential for infants, especially those undergoing phototherapy. Dehydration can worsen jaundice, so the baby should be encouraged to feed frequently.

Choice C rationale:

Placing eye shields over the newborn's closed eyes is essential during phototherapy. Exposure to high-intensity light can damage the baby's eyes, so protecting the eyes with shields is necessary.

Choice D rationale:

Changing the newborn's position every 2-3 hours is recommended during phototherapy. This helps ensure that all parts of the baby's skin receive equal exposure to the light, maximizing the effectiveness of the treatment.

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A laboring woman is lying in the supine position.The most appropriate nursing action at this time is to:.

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Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment on a child and notes the presence of Koplik's spots. In which communicable disease are Koplik's spots present?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A laboring woman is lying in the supine position.
The most appropriate nursing action at this time is to:.