A nurse is caring for a patient who has been admitted to the labor and delivery unit.
After reviewing the patient’s vital signs and nurse’s notes, what condition is the patient most likely experiencing, what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the patient’s progress?
Potential Condition: Preterm labor
Actions to Take: Administer tocolytics
Parameters to Monitor: Frequency of contractions .
Parameters to Monitor: Frequency of contractions .
The Correct Answer is A
Potential Condition: Preterm labor. Based on the information provided, the patient is most likely experiencing preterm labor. Actions to Take: Administer tocolytics. If the patient is in preterm labor, the nurse should administer tocolytics to try to stop the contractions. Parameters to Monitor: Frequency of contractions. The nurse should monitor the frequency of contractions to assess the patient’s progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Intermittent abdominal pain following the passage of bloody mucus can be a sign of labor or other complications, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice B rationale
Painless red vaginal bleeding is a classic symptom of placenta previa. This occurs because the placenta is covering part or all of the cervix, leading to bleeding as the cervix begins to thin and open in preparation for labor.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice D rationale
Increasing abdominal pain with a non-relaxed uterus could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Correct Answer is ["A","B","C"]
Explanation
The correct answers are A. Start breastfeeding with the nipple that is less sore, B. Change the infant’s position on the nipples, and C. Apply breast milk to the nipples before each feeding.
Choice A rationale:
Starting breastfeeding with the nipple that is less sore can help reduce discomfort. The baby tends to suck more vigorously at the beginning of a feeding, so starting with the less sore nipple can minimize pain.
Choice B rationale:
Changing the infant’s position on the nipples can help distribute the pressure more evenly and prevent further irritation of sore areas. Different positions can also help ensure a better latch.
Choice C rationale:
Applying breast milk to the nipples before each feeding can soothe and promote healing of sore nipples. Breast milk has natural antibacterial properties and can help keep the nipples moisturized.
Choice D rationale:
Massaging the breasts and nipples prior to feeding is not typically recommended for reducing nipple soreness. It can potentially cause more irritation and discomfort.
Choice E rationale:
Placing breast pads inside the nursing bra can help absorb leakage and keep the nipples dry, but it does not directly reduce soreness during breastfeeding. It is more of a preventive measure to maintain hygiene.
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