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:
It is not inappropriate because of the child's age. Simple magic tricks, especially those using familiar items like gauze, can capture the attention and cooperation of young children. Age-appropriate distractions can be highly effective in engaging pediatric patients during medical procedures.
Choice B rationale:
Using a simple magic trick with gauze is a way to establish rapport with the child. Children often respond well to creative and playful approaches, making them feel more comfortable and cooperative during medical procedures. Establishing rapport is crucial for gaining trust and ensuring a positive healthcare experience.
Choice C rationale:
It is not too distracting when cooperation is important. Distractions, when used judiciously, can enhance cooperation during medical procedures. The key is to strike a balance between engaging the child and ensuring the procedure's effectiveness. A simple magic trick with gauze is generally not overly distracting and can be a helpful technique in pediatric nursing.
Choice D rationale:
Adequate time is important, but the appropriateness of the magic trick is not solely dependent on time. While having adequate time is beneficial for implementing creative approaches, the effectiveness of using a magic trick depends more on the nurse's skill, the child's response, and the overall context of the situation.
Correct Answer is C
Explanation
Choice A rationale:
Ribbon-like stools are more characteristic of conditions like irritable bowel syndrome (IBS) or colorectal cancer, not intussusception. Intussusception is a medical emergency where one segment of the intestine telescopes into another, leading to obstruction and potentially compromised blood flow.
Choice B rationale:
Hard stools positive for guaiac are suggestive of constipation and are not specific to intussusception. In intussusception, the stool characteristics are usually not relevant to the diagnosis as the condition primarily involves intestinal obstruction.
Choice C rationale:
"Currant jelly" stools are a classic characteristic of intussusception. These stools contain mucus and blood and have a characteristic appearance due to the compromised blood flow and tissue damage in the intestines. Recognizing this stool description is crucial for identifying a potential case of intussusception.
Choice D rationale:
Loose, foul-smelling stools are not specific to intussusception. These symptoms could be indicative of various gastrointestinal issues but are not directly associated with the classic presentation of intussusception, which involves the passage of bloody mucus in the stool.
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