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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Facilitate maternal-newborn interaction. Facilitating maternal-newborn interaction is an important aspect of breastfeeding, but it is not the primary purpose of encouraging breastfeeding immediately after an emergency birth. The primary purpose is to initiate the lactation cycle, allowing the newborn to receive essential colostrum, the first milk rich in antibodies and nutrients, which aids in the development of the newborn's immune system.
Choice B rationale:
Stimulate the uterus to contract. While breastfeeding can stimulate uterine contractions due to oxytocin release, the primary purpose of encouraging breastfeeding in this context is not to contract the uterus but to initiate the lactation cycle for the newborn's benefit.
Choice C rationale:
Prevent neonatal hypoglycemia. Breastfeeding can help prevent neonatal hypoglycemia by providing the newborn with a constant supply of nutrients, but the primary purpose immediately after an emergency birth is to initiate the lactation cycle and provide colostrum, not solely to prevent hypoglycemia.
Choice D rationale:
Initiate the lactation cycle. Initiating the lactation cycle is the correct answer because breastfeeding immediately after birth helps the woman's body start producing milk and provides the newborn with colostrum, essential for their health and development. Colostrum is rich in antibodies and nutrients, offering vital protection and nourishment to the newborn.
Correct Answer is A
Explanation
Choice A rationale:
An Apgar score of 10 at 1 minute after birth indicates that the infant is in excellent condition, adjusting well to extrauterine life, and requires no further testing or interventions at that moment. The Apgar score assesses the baby's heart rate, respiratory effort, muscle tone, reflexes, and color, with a maximum score of 10. An Apgar score of 10 suggests that the baby is pink, has a heart rate above 100 beats per minute, exhibits strong cries, has active motion, and demonstrates good muscle tone.
Choice B rationale:
An Apgar score of 10 does not indicate severe distress requiring resuscitation. A low Apgar score (typically below 7) at 1 minute may prompt further evaluation and interventions to support the baby's transition to extrauterine life.
Choice C rationale:
While a high Apgar score is reassuring, it does not predict a future free of neurologic problems. The Apgar score assesses the baby's current condition and provides a snapshot of their overall well-being at birth.
Choice D rationale:
Although the Apgar score is assessed at 1 and 5 minutes after birth, a score of 10 at 1 minute suggests that the baby is doing well at that moment. However, the baby should still be assessed again at 5 minutes to ensure continued stability and appropriate interventions if necessary.
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