Temp 98.6 (0)
Sp02 98% on RA
What three priority assessments will you make for this patient?
Abdominal girth q 2 hours.
Assess amount of bleeding
Pelvic exam for cervical dilation.
Fetal heart rate patterns
Maternal vital signs
Attach internal fetal scalp electrode.
Correct Answer : B,D,E
A. Abdominal girth is not a primary concern for this patient. Monitoring for signs of abdominal distention and changes in the uterus is more relevant for conditions like preeclampsia or uterine rupture.
B. Assessing the amount of bleeding is essential as vaginal bleeding can indicate serious complications like placental abruption or previa.
C. A pelvic exam is not indicated without signs of cervical change or labor. The priority is to assess for active bleeding and fetal well-being.
D. Fetal heart rate patterns are crucial to assess the status of the fetus, particularly with the concern of placental issues.
E. Maternal vital signs are important to monitor to detect signs of shock or bleeding complications that may not be immediately obvious.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calcium gluconate is used for hypocalcemia, not for treating hypotension.
B. Ephedrine is a vasopressor used to treat hypotension, which can occur as a side effect of epidural anesthesia by helping to increase blood pressure.
C. Apresoline is an antihypertensive and would not be appropriate for treating hypotension.
D. Nifedipine is a calcium channel blocker used for hypertension, not for treating hypotension related to epidural anesthesia.
Correct Answer is ["D","F"]
Explanation
A. Brethine (Terbutaline) is typically used for stopping premature labor but is not recommended for all patients as it can have side effects like tachycardia and decreased uterine contractions. The patient does not appear to need to stop labor immediately, and other interventions are more appropriate.
B. Pitocin (Oxytocin) is used to augment labor but is not indicated in a case of early labor unless there is a need to speed up contractions or induce labor after a period of observation.
C. Misoprostol (Cytotec) is a medication used to ripen the cervix, but it’s not appropriate here as the patient is only 2 cm dilated and doesn't show indications for labor induction.
D. Betamethasone is used to promote fetal lung maturity in cases of preterm labor. Given the patient is at 34 weeks, this would be an appropriate intervention.
E. Oxytocin (Pitocin) would only be used for augmentation or induction in a more advanced labor situation, and it's not needed at this stage.
F. IV Fluids are important in this case to maintain hydration and possibly prevent preterm labor, as dehydration can exacerbate contractions.
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