Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

Maintaining the infants’ airways.

Keeping the infants in a warm, draft-free environment.

Placing identification bands on the infants.

Monitoring the infants’ vital signs.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery. This is because twins are more likely to be born early and need special care after birth than single babies. They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well. Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL

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Correct Answer is C

Explanation

This is because the patient is experiencing supine hypotension syndrome, which occurs when the weight of the gravid uterus compresses the inferior vena cava and reduces venous return and cardiac output. Turning the patient onto her side will relieve the pressure and improve blood flow.

Choice A is wrong because taking the patient’s blood pressure will not address the cause of her symptoms and may delay appropriate intervention.

Choice B is wrong because breathing into her cupped hands will not improve her circulation and may increase her carbon dioxide levels.

Choice D is wrong because elevating the patient’s legs will not relieve the compression of the inferior vena cava and may worsen her condition.Normal blood pressure for a pregnant woman is 110/70 to 120/80 mmHg.Normal heart rate for a pregnant woman is 60 to 90 beats per minute.Normal respiratory rate for a pregnant woman is 16 to 24 breaths per minute.

A. “I’ll elevate my legs to relieve my leg cramps.”. B. “My husband will massage my legs when I get cramps.”. C. “Stretching my legs and pointing my toes toward my knee will bring relief from the leg cramps.” D. “I’ll put a cold compress on the calf of my leg when I get a cramp.”.

Correct Answer is C

Explanation

The correct answer is choice C. Stretching your legs and pointing your toes toward your knee will bring relief from the leg cramps.This is because stretching can help relax the muscle and ease the spasm.

Choice A is wrong because elevating your legs may not help with leg cramps, and may actually worsen them by reducing blood flow to the muscles.

Choice B is wrong because massaging your legs may not be enough to relieve the cramps, and may also cause more pain if done too hard or too fast.

Choice D is wrong because putting a cold compress on the calf of your leg may not be effective for leg cramps, and may also cause more discomfort or inflammation.

Leg cramps are common during pregnancy, especially in the second and third trimester.They are caused by various factors, such as pregnancy weight gain, changes in blood circulation, pressure on the nerves and blood vessels, nutrient deficiency, lack of exercise, or fluid buildup in your legs.To prevent or reduce leg cramps, you should drink plenty of water, stay active, eat a balanced diet rich in calcium, magnesium, and potassium, avoid standing or sitting for long periods of time, wear comfortable shoes and socks, and sleep on your left side with a pillow under or between your legs.

If leg cramps persist or become severe, you should consult your healthcare provider for possible treatment options.

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Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

During a regular clinic visit, a patient who is 28 weeks pregnant reports leg cramps. The nurse teaches the patient measures to relieve the cramps. Which statement would indicate that the patient understands the teaching?

Correct Answer is C

Explanation

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