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 B
Explanation
Choice A rationale:
Preventing the spread of illness to others is not the primary focus when teaching a mother about ulcerative colitis. Ulcerative colitis is a chronic inflammatory bowel disease and is not contagious. The primary focus of education should be related to managing the child's symptoms and improving their quality of life.
Choice B rationale:
Nutritional guidance and preventing constipation are essential aspects of managing ulcerative colitis. Proper nutrition helps support the child's overall health and well-being. Additionally, preventing constipation is crucial in managing symptoms and reducing discomfort for children with ulcerative colitis.
Choice C rationale:
Teaching daily use of enemas may be relevant in specific cases or during acute flare-ups, but it is not a general teaching point for all children with ulcerative colitis. Enema usage should be based on the healthcare provider's recommendation and tailored to the individual child's needs.
Choice D rationale:
Coping with stress and avoiding triggers is important in managing ulcerative colitis. Stress and certain triggers can exacerbate symptoms and lead to flare-ups. Teaching coping mechanisms and identifying triggers can help the child and their family manage the condition effectively.
Correct Answer is ["A","B"]
Explanation
Choice A rationale:
The cuff labeled "toddler" is an appropriate criterion for selecting the right-sized blood pressure cuff for a 2-year-old boy. Pediatric blood pressure cuffs are available in different sizes, and using a cuff specifically labeled for toddlers ensures a proper fit and accurate blood pressure measurement.
Choice B rationale:
The cuff bladder width being approximately 40% of the circumference of the upper arm is a correct criterion. Using a cuff with an appropriate width ensures that the cuff covers a significant portion of the upper arm, allowing for accurate blood pressure measurement. A cuff that is too narrow or too wide can lead to inaccurate readings.
Choice C rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm is an incorrect criterion. The length of the cuff bladder should cover about 80% of the upper arm's circumference, not 80% to 100%. Using a cuff that is too long can result in falsely low blood pressure readings.
Choice D rationale:
The cuff bladder covering 50% to 66% of the length of the upper arm is an incorrect criterion. The bladder width, which covers the circumference of the upper arm, is more critical than the length. The width should be approximately 40% of the upper arm's circumference for accurate blood pressure measurement in children.
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