The nurse is preparing for the care of a baby about to be delivered by caesarean section. What interventions will the nurse include in the plan of care? Select all that apply.

Obtain an arterial blood gas.

Ensure thermoregulation.

Administer oxygen as needed.

Insert an orogastric tube.

Keep the head in a sniffing position.

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: Obtaining an arterial blood gas is not typically a routine intervention immediately following a caesarean section. Arterial blood gas measurements are usually performed if there is a specific indication or concern about the baby's respiratory status or acid-base balance. Routine care focuses on stabilizing and assessing the baby rather than performing invasive procedures unless clinically indicated.

Choice B reason: Ensuring thermoregulation is a crucial intervention for newborns, especially those delivered by caesarean section. Maintaining an appropriate body temperature is essential to prevent hypothermia, which can lead to complications such as metabolic disturbances and respiratory issues. The nurse should use measures like pre-warmed blankets and radiant warmers to keep the baby warm and stable.

Choice C reason: Administering oxygen as needed is an important intervention to ensure the baby's oxygenation and respiratory stability. Newborns delivered by caesarean section may have transient respiratory difficulties due to the lack of the natural squeeze through the birth canal, which helps clear the lungs of fluid. Monitoring the baby's respiratory status and providing supplemental oxygen if necessary is vital for their well-being.

Choice D reason: Inserting an orogastric tube is not a standard routine intervention immediately after a caesarean section unless there is a specific indication, such as if the baby has difficulty feeding, significant respiratory distress, or gastrointestinal issues. Routine care focuses on more immediate stabilization measures unless clinical signs suggest the need for an orogastric tube.

Choice E reason: Keeping the head in a sniffing position is important for maintaining an open airway and ensuring effective ventilation. The sniffing position aligns the airway and promotes optimal breathing. This position is particularly useful for newborns who may have respiratory difficulties or require resuscitation efforts, ensuring that their airway remains patent and clear.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Placing the patient in a supine position is not recommended in cases of suspected partial placental abruption. The supine position can compress the inferior vena cava, reducing blood flow to the placenta and potentially worsening the condition. Instead, a lateral position is generally preferred to enhance blood flow.

Choice B reason: Encouraging oral intake is not a priority action in this scenario. In cases of suspected placental abruption, the patient may need to undergo emergency medical procedures, and maintaining an empty stomach is often advised to prevent aspiration if anaesthesia is required.

Choice C reason: Administering IV fluids is crucial in managing suspected partial placental abruption. This intervention helps maintain maternal blood pressure and ensures adequate blood flow to the placenta, which is essential for fatal well-being. IV fluids can also be vital in managing any potential blood loss.

Choice D reason: Evaluating fatal heart rate monitoring is essential to assess the foetus’s well-being. Continuous monitoring allows the healthcare team to detect any signs of fatal distress, which can guide further medical interventions and decision-making processes.

Choice E reason: Monitoring maternal pain is a critical component of managing suspected partial placental abruption. Pain assessment helps determine the severity of the abruption and the effectiveness of pain management strategies. It also provides valuable information about the patient's condition and the need for additional interventions.

A. Maternal hypertension B. Postpartum haemorrhage C. Newborn hyperglycaemia D. Premature rupture of membranes

Correct Answer is B

Explanation

Choice A reason: Maternal hypertension, or high blood pressure, is not directly associated with precipitous Labor. While hypertension can be a concern during pregnancy, it is not a primary complication resulting from a rapid Labor process. The nurse's focus would be on other specific complications that arise from precipitous Labor.

Choice B reason: Postpartum haemorrhage is a significant risk for patients experiencing precipitous Labor. Rapid Labor can lead to excessive uterine contractions, which might cause trauma to the birth canal, including lacerations and uterine atony (failure of the uterus to contract properly after delivery). These conditions can lead to significant blood loss and necessitate close monitoring and intervention to manage and mitigate the haemorrhage.

Choice C reason: Newborn hyperglycaemia, which refers to elevated blood sugar levels in the newborn, is not related to the process of precipitous Labor. This condition is more commonly associated with maternal diabetes and is not a typical complication the nurse would monitor for in this scenario.

Choice D reason: Premature rupture of membranes, which refers to the breaking of the amniotic sac before Labor begins, is not a complication resulting from precipitous Labor. It is a condition that can precede Labor but is not caused by the rapid progression of Labor. The nurse would be more concerned with managing complications directly related to the rapid Labor and delivery process.

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The nurse is preparing for the care of a baby about to be delivered by caesarean section. What interventions will the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a primigravida at 36-weeks gestation admitted with suspected partial placental abruption. What actions will the nurse implement? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is B

Explanation

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