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","C","E"]

Explanation

Choice A rationale:
Correction of acidosis is not the primary intervention for vaso-occlusive sickle cell crisis. The crisis primarily involves pain due to the obstruction of blood flow by sickled cells. Correcting acidosis is not a direct treatment for this condition.
Choice B rationale:
Adequate hydration is essential in managing vaso-occlusive sickle cell crisis. Proper hydration helps prevent dehydration, which can worsen the crisis and lead to complications. Hydration helps maintain blood flow and prevent further sickling of red blood cells.
Choice C rationale:
Pain management is a crucial intervention for a child with vaso-occlusive sickle cell crisis. Pain results from tissue ischemia caused by sickled red blood cells. Effective pain management, often with analgesics, helps improve the child's comfort and quality of life during the crisis.
Choice D rationale:
Administration of heparin is not indicated for vaso-occlusive sickle cell crisis. Heparin is an anticoagulant that prevents blood clot formation. In sickle cell crisis, the primary issue is the obstruction of blood flow by sickled cells, not the formation of clots. Administering heparin may not address the underlying problem and can lead to potential complications.
Choice E rationale:
Replacement of factor VIII is not relevant to vaso-occlusive sickle cell crisis. Factor VIII is a protein involved in blood clotting and is primarily used in the treatment of hemophilia, a different condition unrelated to sickle cell crisis.

A. suffering from sleep or wakeful apnea. B. experiencing severe swings in blood pressure. C. trying to maintain a neutral thermal environment. D. breathing in a respiratory pattern common to premature infants.

Correct Answer is A

Explanation

Choice A rationale:

The correct answer. Apnea in premature infants, characterized by pauses in breathing lasting 5 to 10 seconds, is often due to immature central respiratory centers in the brain. These episodes are termed sleep or wakeful apnea and are a common phenomenon in premature infants. The compensatory rapid respiration that follows is the body's attempt to restore oxygen levels.

Choice B rationale:

There is no indication in the scenario that the infant is experiencing severe swings in blood pressure, which would be a concerning condition that would need medical attention.

Choice C rationale:

Premature infants require a neutral thermal environment, but this condition does not cause the specific respiratory pattern described in the question.

Choice D rationale:

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child's care should include which intervention? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:.

Correct Answer is A

Explanation

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