By identifying recurring themes in NCLEX RN Practice Questions students can focus on key content areas that are frequently tested.
NCLEX Obstetrics and Gynaecology Questions - NCLEX Questions on Obstetrics and Gynaecology
Obstetrics and Gynaecology NCLEX Practice Questions
Question 1.
A woman has just had a radiation implant inserted into her cervix to treat her cervical cancer.
Which of the following is the appropriate care for a client with radiation implants?
(a) Keep the client in a shared room
(b) Permit pregnant caretakers or pregnant visitors into the room
(c) Do not wear a dosimeter when providing care to clients with radiation implants
(d) Keep a lead-lined container in the room for disposal of the implant should it become dislodged
(e) Client should remain active and mobile
(f) Use latex gloves when handling potentially contaminated secretions
Answer:
(f) Use latex gloves when handling potentially contaminated secretions
Explanation:
(b) Permit pregnant caretakers or pregnant visitors into the room - This is incorrect as pregnant individuals should not be permitted into the room of a client with radiation implants. Pregnant individuals are at a higher risk of harm from radiation exposure, and thus should be kept away from the client.
(d) Keep a lead-lined container in the room for disposal of the implant should it become dislodged - This is one of the appropriate measures for a client with radiation implants. A lead-lined container should be kept in the room to ensure safe disposal of the implant should it become dislodged.
(a) Keep the client in a shared room - This is incorrect as the client should be assigned to a private room with a "Caution: Radioactive Material" sign on the door to ensure that others are aware of the potential risks.
(c) Do not wear a dosimeter when providing care to clients with radiation implants - This is incorrect as all staff members providing care should wear a dosimeter during every client contact to monitor radiation exposure.
(e) Client should remain active and mobile - This is incorrect as the client should remain in bed with as little movement as possible to minimize the potential dislodgment of the implant.
(f) Use latex gloves when handling potentially contaminated secretions - This is one of the appropriate measures for a client w'ith radiation implants. Latex gloves should be used when handling potentially contaminated secretions as all client secretions have the potential of being radioactive.
Question 2.
Ms. Brown, a 32-year-old primigravida, arrives at the hospital in active labor at 39 weeks gestation. She has had a low-risk pregnancy and has been attending regular prenatal check-ups. Her vital signs are within normal limits, and she reports that she has been experiencing contractions every 5-7 minutes that last for 45-60 seconds. Upon vaginal examination, the midwife detennines that the fetal head is engaged and in a left occipitoanterior position. Ms. Brown is admitted to the labor and delivery unit and a fetal heart rate monitor is applied.
Which of the following is the process in which the fetal head undergoes as it begins its journey through the pelvis?
(a) Engagement
(b) Descent
(c) Flexion
(d) External Rotation
Answer:
(b) Descent
Explanation:
Descent is the process in which the fetal head undergoes as it begins its journey through the pelvis. It is a continuous process from prior to engagement until birth and is assessed by the measurement called station. Engagement is the mechanism whereby the fetus nestles into the pelvis. Flexion is a process of nodding of the fetal head forward toward the fetal chest. External rotation occurs after the head emerges and restitution occurs, so that the shoulders are in the anteroposterior diameter of the pelvis. Therefore, option (b) is the correct answer.
Question 3.
A 25-year-old female presents with lower abdominal pain and fever. She reports having multiple sexual partners over the past few months. On examination, there is tenderness in the lower abdomen and cervical motion tenderness. A diagnosis of pelvic inflammatory disease (PID) is made.
What is the appropriate management for this patient?
Which of the following options is/are appropriate management for a patient diagnosed with pelvic inflammatory disease?
(a) Increase sexual contacts
(b) Avoid sex with those who have multiple partners
(c) Examine genital area and avoid sexual contact if anything abnormal is present
(d) Wash hands and genital area before and after sexual contact
(e) Use a latex condom as a barrier
(f) Use water-based lubricants rather than oil-based lubricants
(g) Use a vaginal spermicidal gel
(h) Avoid douching before and after sexual contact
(i) Seek attention from health care provider immediately if symptoms occur
Answer:
(b) Avoid sex with those who have multiple partners
(i) Seek attention from health care provider immediately if symptoms occur
Explanation:
Pelvic inflammatory disease (PID) is a serious infection of the reproductive organs that can result in significant complications if left untreated. Antibiotic treatment is necessary to reduce inflammation and pain, and should be effective for Neisseria gonorrheae and Chlamydia trachomatis. In addition to antibiotic treatment, there are several other management strategies that can help reduce the risk of complications and promote healing.
Option (a) Increase sexual contacts - This option is incorrect. Increasing sexual contacts can increase the risk of further infections and complications.
Option (b) Avoid sex with those who have multiple partners - This option is correct. Avoiding sex with those who have multiple partners can reduce the risk of further infections and complications.
Option (c) Examine genital area and avoid sexual contact if anything abnormal is present - This option is not specific to PID management and may not be necessary in all cases.
Option (d) Wash hands and genital area before and after sexual contact - This option is a good hygiene practice, but it is not specific to PID management.
Option (e) Use a latex condom as a barrier - This option is a good practice to reduce the risk of sexually transmitted infections, but it may not be sufficient to prevent PID.
Option (f) Use water-based lubricants rather than oil-based lubricants - This option is a good practice to reduce the risk of irritation and infection, but it is not specific to PID management.
Option (g) Use a vaginal spermicidal gel - This option is not specific to PID management and may not be necessary in all cases.
Option (h) Avoid douching before and after sexual contact; douching increases risk for infections because the body’s normal defenses are reduced or destroyed - This option is a good practice to reduce the risk of infection and irritation, but it is not specific to PID management.
Option (i) Seek attention from health care provider immediately if symptoms occur - This option is correct. Seeking attention from a healthcare provider immediately if symptoms occur is important to prevent complications and ensure prompt treatment.
Question 4.
Mrs. Ranjan is a 32-year-old woman in her third trimester of pregnancy. She has a history of hypertension and preeclampsia in her current pregnancy. Which of the following techniques would be most appropriate to assess fetal and maternal well-being in this case?
(a) Fetal heart rate monitoring only
(b) Fetal heart rate monitoring and ultrasound
(c) Ultrasound only
(d) Nonstress test only
(e) Biophysical profile only
(f) Nonstress test and biophysical profde
Answer:
(b) Fetal heart rate monitoring and ultrasound
(f) Nonstress test and biophysical profde
Explanation:
Fetal and maternal assessment techniques are important in determining the health and well-being of both the mother and fetus during pregnancy. Maternal risk factors, such as those listed in the description, can increase the likelihood of complications during pregnancy and therefore require more frequent and thorough monitoring.
Fetal heart rate monitoring, ultrasound, nonstress tests, and biophysical profiles are all techniques used to assess fetal and maternal well-being. Fetal heart rate monitoring measures the fetal heart rate, which can indicate fetal distress. Ultrasound can provide information on fetal growth and development, as well as detect any abnonnalities. Nonstress tests measure fetal heart rate in response to fetal movement, and biophysical profiles assess fetal breathing, movement, tone, and amniotic fluid levels.
A combination of these techniques is often used to provide a more complete picture of fetal and maternal health during pregnancy, especially in cases where there are maternal risk factors or indications of fetal distress. Mrs. Ranjan is at an increased risk for complications during pregnancy due to her history of hypertension and preeclampsia. Therefore, a combination of fetal heart rate monitoring and ultrasound, as well as a nonstress test and biophysical profile, would be the most appropriate techniques to assess fetal and maternal well-being.
Option (a), fetal heart rate monitoring only, would not provide enough information about maternal well-being or the overall health of the fetus.
Option (c), ultrasound only, would not provide information on fetal heart rate, which is an important indicator of fetal well-being.
Option (d) nonstress test only, would provide some information about fetal well-being, but not enough to assess maternal well-being or overall fetal health.
Option (e) biophysical profde only, would provide information on fetal well-being, but not enough to assess maternal well-being or overall fetal health.
Therefore, options (b) and (f), which include a combination of techniques, would be the most appropriate to assess fetal and maternal well-being in this case.
Question 5.
Dr. Ranjan is a pediatrician who is conducting a neonatal assessment of a newborn baby. As part of the assessment, Dr. Ranjan checks for various physical and reflex characteristics. During the examination. Dr. Ranjan notices that the baby is lacking on the entire sole of the feet. What could be the potential implications of this observation?
Fill in the blank type question: What physical characteristic is typically absent in premature or genetically disordered newborns?
(a) Babinski reflex
(b) Epstein's pearl
(c) Lanugo hair
(d) Planter creases
Answer:
(d) Planter creases.
Explanation:
As mentioned, planter creases are present on the entire sole of a newborn, and their absence may indicate prematurity or a genetic disorder. Therefore, the correct answer is option D. Babinski reflex, Epstein's pearl, and lanugo hair are all physical characteristics that may be present in newborns, but their presence or absence does not necessarily indicate prematurity or a genetic disorder.
(a) Babinski reflex: The Babinski reflex is a primitive reflex that is present in newborns. It is elicited by stroking the lateral surface of the sole of the foot, which causes the toes to hyperextend and fan out. This reflex is normally present in newborns and typically disappears around 12 months of age. The presence or absence of the Babinski reflex can be an indicator of neurologic health in a newborn. In some cases, the Babinski reflex may persist beyond infancy, which can be a sign of a neurologic disorder.
(b) Epstein's pearl: Epstein's pearl is a white, pearl-like epithelial cyst that can appear on the gums or palate of newborns. These cysts are harmless and typically disappear within a few weeks after birth. Epstein's pearls are caused by trapped epithelial cells during the development of the baby's mouth.
(c) Lanugo hair: Lanugo hair is fine, downy hair that covers the entire body of some newborns. This hair is typically present on premature infants and usually disappears by the time the baby reaches full term. Lanugo hair is thought to help regulate the baby's body temperature and protect their skin in utero.
(d) Planter creases: Planter creases are the lines or creases that appear on the entire sole of the feet of newborns. These creases are formed during fetal development and are present in most newborns. The absence of planter creases on the entire sole of the feet may indicate prematurity or a genetic disorder, such as Down syndrome. However, the absence of planter creases alone is not enough to diagnose a disorder and further evaluation and testing would be needed to confirm any potential issues.
Question 6.
Sanjeeta is a 26-year-old woman who is experiencing her first pregnancy. She is currently in the latent phase of labor. What should the nurse do during this phase?
(a) Measure the duration of the latent phase and allow the patient to be continually active.
(b) Conduct internal examinations frequently to assess cervical dilation.
(c) Administer anesthesia to help with contraction pains.
(d) Conduct interviews and filling in of forms during the active phase of labor.
Answer:
(a) Measure the duration of the latent phase and allow the patient to be continually active.
Explanation:
It is important to note that the latent phase can vary in duration and that the 6-hour limit for nulliparas and 4.5-hour limit for multiparas are guidelines. Some women may have a longer or shorter latent phase, and this is considered normal as long as it does not indicate CPD or other complications. The nurse should monitor the patient closely and assess for any signs of distress or complications during this phase. The nurse should also provide continuous maternal support to help the patient cope with labor and provide emotional support.
During the latent phase, the nurse should measure the duration of the phase to ensure that it does not exceed 6 hours for nulliparas or 4.5 hours for multiparas. This is important because a prolonged latent phase can indicate cephalopelvic disproportion (CPD), which may require a cesarean birth. The nurse should also allow the patient to be continually active and encourage upright maternal positions, which can help with the progression of labor. Internal examinations should be limited to 5 throughout the entire course of labor to prevent infection and discomfort for the patient. Anesthesia should not be administered during the latent phase unless it is medically necessary.
The nurse should conduct interviews and fill in forms during this phase while the patient experiences minimal discomfort and has control over contraction pains. Health teaching on breastfeeding, newborn care, and effective bearing down should also be conducted during this phase, while the patient's anxiety is controlled and she is able to focus on the nurse's instructions. Relaxation techniques should be taught to the patient as early as possible to help with pain relief. Finally, the birthing companion of choice should be present all throughout the course of labor to provide emotional support to the patient.
Question 7.
A pregnant woman comes to the clinic concerned about sexually transmitted infections (STIs). She asks the nurse about the risks of STIs to her unborn baby. Which of the following STIs can result in neonatal conjunctivitis or pneumonitis if transmitted during vaginal birth?
(a) Syphilis
(b) Condyloma acuminatum (human papillomavirus)
(c) Gonorrhea
(d) Chlamydial infection
Answer:
(d) Chlamydial infection
Question 8.
A 32-year-old pregnant patient was admitted to the labor and delivery unit for induction of labor due to medical reasons. The medical team decided to use oxytocin to facilitate labor progress.
The oxytocin infusion was started at a low dose and gradually increased based on the patient's response.. After some time, the medical team immediately stopped the oxytocin infusion and performed an emergency cesarean birth to deliver the baby safely.
What potential risks can oxytocin use carry during labor induction or augmentation in pregnant patients?
(a) Increase the risk of placenta previa during pregnancy.
(b) Delay milk production in the postpartum period.
(c) Cause contractions that are too strong or frequent, leading to reduced placental blood flow and non-assuring fetal heart patterns.
(d) Increase the risk of postpartum hemorrhage.
Answer:
(c) Cause contractions that are too strong or frequent, leading to reduced placental blood flow and non-assuring fetal heart patterns.
Explanation:
Option (a) is incorrect because oxytocin does not increase the risk of placenta previa during pregnancy. Option (b) is incorrect because oxytocin does not delay milk production in the postpartum period. In fact, oxytocin can decrease postpartum hemorrhage by promoting uterine contractions after birth.
Option (c) is the correct answer because oxytocin can cause contractions that are too strong or frequent, leading to reduced placental blood flow and non-assuring fetal heart patterns, such as late deceleration, fetal bradycardia, tachycardia, or minimal variability, which may require emergency cesarean birth. It is important for medical professionals to carefully monitor the use of oxytocin during labor induction or augmentation to prevent potential risks to the mother and baby.
Option (d) is incorrect because oxytocin can actually decrease the risk of postpartum hemorrhage by promoting uterine contractions after birth.
Question 9.
What should the nurse observe for after birth when a patient has received oxytocin for a longer period?
(a) Fetal bradycardia
(b) Reduced placental blood flow
(c) Delayed milk production
(d) Postpartum hemorrhage
Answer:
(d) Postpartum hemorrhage
Rationale:
After birth, the nurse should observe for signs of postpartum hemorrhage, especially if the patient has received oxytocin for a longer period. Oxytocin can cause fatigue in the uterine muscles, which may not contract effectively to compress vessels at the placental site and prevent bleeding.
Question 10.
How does oxytocin affect milk production in lactating patients?
Possible answer choices:
(a) It delays milk production
(b) It promotes milk production
(c) It has no effect on milk production
(d) It decreases milk production
Answer:
(b) It promotes milk production
Explanation:
Chlamydial infection is an STI that can be transmitted from the mother to her newborn during vaginal birth. The infection can cause neonatal conjunctivitis or pneumonitis. Other risks to the neonate include premature rupture of the membranes, premature labor, and postpartum endometritis.
Option (a) Syphilis is an STI that can cross the placenta, leading to spontaneous abortions and increasing the incidence of mental subnormality and physical deformities. This infection does not directly cause neonatal conjunctivitis or pneumonitis.
Option (b) Condyloma acuminatum (human papillomavirus) is an STI that can be transmitted during vaginal birth and is associated with the development of epithelial tumors of the mucous membranes of the larynx in children. This infection does not cause neonatal conjunctivitis or pneumonitis.
Option (c) Gonorrhea is an STI that can contaminate the fetus during birth and can result in postpartum infection of the neonate. Risks to the neonate include ophthalmia neonatorum, pneumonia, and sepsis. While gonorrhea can cause neonatal complications, it does not directly cause neonatal conjunctivitis or pneumonitis.
Option (d) Chlamydial infection can be transmitted during vaginal birth and can result in neonatal conjunctivitis or pneumonitis. Infection can also cause premature rupture of the membranes, premature labor, and postpartum endometritis.
Option (e) Human immunodeficiency virus (HIV) is transmitted through blood, blood products, bodily fluids, and exposure to infected secretions during birth and through breast milk. The repeated exposure to the virus during pregnancy through unsafe sex practices or intravenous drug use can increase the risk of transmission to the fetus. Perinatal administration of zidovudine may be recommended to decrease the risk of transmission of HIV from mother to fetus. HIV does not directly cause neonatal conjunctivitis or pneumonitis.
Rationale:
Oxytocin is secreted by the pituitary gland and plays a role in the let-down reflex, which releases milk from the alveoli and facilitates milk ejection during breastfeeding. Prolactin, another hormone, is responsible for milk production, but oxytocin can enhance its effects and promote milk flow.
Question 11.
Ms. Miranda is a 28-year-old primigravida who has just been admitted to the hospital in active labor. Upon assessment, the nurse notes that she is at 4 cm cervical dilatation. What nursing interventions should be implemented during this phase of labor?
(a) Administer pain medication to provide relief
(b) Encourage the patient to lie flat on her back
(c) Monitor maternal vital signs and fetal heart rate every 4 hours
(d) Institute non-pharmacological pain measures
Answer:
(d) Institute non-pharmacological pain measures
Explanation:
During the active phase of labor, the patient experiences stronger contractions, shorter intervals, and longer durations. The patient's discomfort may increase during this phase, and she may be focused on herself. Therefore, nursing interventions should focus on providing comfort and support. Administering pain medication is not recommended during the active phase, as the patient's pain level may not yet warrant the use of medication.
Additionally, encouraging the patient to lie flat on her back is not recommended, as upright maternal positions are recommended to maximize the effect of uterine contractions. Monitoring maternal vital signs and fetal heart rate every 4 hours is not sufficient, as it is recommended to monitor them every 2 hours or depending on the doctor's order. Therefore, the correct answer is D. Institute non- pharmacological pain measures, which include breathing exercises, distraction methods, imagery, music therapy, and other non-invasive techniques to provide comfort and support to the patient during labor.
In addition to the nursing interventions listed in the case study, it is also important to note that during the active phase of labor, the nurse should assess the patient's pain level and provide appropriate pain management. Non-pharmacological pain measures should be tried first, but if the patient's pain becomes unmanageable, pharmacological interventions may be necessary.
It is also important to monitor the progress of labor using a WHO partograph, as this can help identify any deviations from normal labor and allow for prompt intervention. Finally, the nurse should continue to encourage the patient to be active and assume positions of comfort, while also providing emotional support and reassurance throughout the labor process.
Question 12.
Mrs. Malla gave birth to a healthy baby girl at 8:00 AM. The nurse on duty is now monitoring her during the third stage of labor or the active phase. Which of the following is not a sign of placental separation during the active phase?
(a) Lengthening of umbilical cord
(b) Sudden gush of vaginal blood
(c) Change in the shape of uterus (globular in shape)
(d) Appearance of placenta in vaginal opening
Answer:
(d) Appearance of placenta in vaginal opening
Explanation:
During the active phase or third stage of labor, placental separation occurs. The signs of placental separation include lengthening of the umbilical cord, sudden gush of vaginal blood, change in the shape of the uterus (globular in shape), and firm uterine contractions. The appearance of the placenta in the vaginal opening is a sign of placental expulsion, which is the second phase of the third stage of labor. Placental expulsion occurs after placental separation and is characterized by the expulsion of the placenta using gentle traction on the cord. Therefore, option (d) is incorrect.
During the active phase or third stage of labor, it is essential for nurses to provide appropriate nursing care to the mother to prevent complications such as infection and hemorrhage. The nursing care tips during the active phase include coaching the mother in relaxation for the delivery of the placenta, congratulating her on the delivery of the baby, encouraging skin-to-skin contact to facilitate bonding and early breastfeeding, administering prophylactic oxytocin as ordered, utilizing controlled cord traction technique for placental expulsion, and utilizing absorbable synthetic suture materials for primary repair of episiotomy or perineal lacerations.
It is also crucial for nurses to check the vital signs and monitor for excessive bleeding during the immediate postpartum period. The WHO recommendations for immediate postpartum include early resumption of feeding, prophylactic antibiotics for women who sustained third to fourth-degree perineal tear during delivery, and early postpartum discharge for healthy women who delivered vaginally to term infants. The routine use of ice packs and oral methylergometrine for patients who delivered vaginally are not recommended during immediate postpartum.
Question 13.
A 1-day-old newborn is admitted to the neonatal intensive care unit (NICU) with acrocyanosis. What is the recommended initial nursing management for this newborn?
(a) Administer oxygen
(b) Count respiratory rate
(c) Monitor heart sounds
(d) Evaluate for potential respiratory or cardiac abnormalities
(e) Keep neonate skin to skin with the mother or use a radiant warmer
Answer:
(e) Keep neonate skin to skin with the mother or use a radiant warmer
Explanation:
Acrocyanosis is a common condition in newborns characterized by blue or purple discoloration of the hands and feet. It occurs due to immature blood circulation and is often considered a normal finding in the first few days after birth. The initial nursing management for a newborn with acrocyanosis is to maintain temperature by keeping the neonate skin to skin with the mother or by using a radiant warmer and frequently monitor the axillary temperature.
This helps to ensure that the newborn stays warm and that their blood circulation improves, which can help to resolve the acrocyanosis. Options (a), (b), and (c) are incorrect as they are not indicated as the initial nursing management for a newborn with acrocyanosis. Option (d) may be necessary to evaluate potential respiratory or cardiac abnormalities, but it is not the recommended initial nursing management for a newborn with acrocyanosis.
Question 14.
Marie has just delivered her baby, and the nurse is monitoring her during the third stage of labor. The nurse notes that the umbilical cord has lengthened, the uterus has a globular shape, and there are firm uterine contractions. Suddenly, there is a gush of vaginal blood, and the nurse notices the appearance of the placenta in the vaginal opening. What should the nurse do next?
(a) Congratulate the patient on the delivery of her baby and administer prophylactic oxytocin as ordered.
(b) Ask the patient whether the placenta is important to them before it is destroyed and encourage skin-to-skin contact to facilitate bonding and early breastfeeding.
(c) Utilize controlled cord traction technique for placental expulsion and coach in relaxation for delivery of placenta.
(d) Utilize absorbable synthetic suture materials (over chromic catgut) for primary repair of episiotomy or perineal lacerations and monitor for excessive bleeding.
Answer:
(c) Utilize controlled cord traction technique for placental expulsion and coach in relaxation for delivery of placenta.
Explanation:
During the third stage of labor or the placental stage, the placenta starts to separate from the contracting uterine wall. The signs of placental separation include lengthening of the umbilical cord, sudden gush of vaginal blood, change in the shape of the uterus (globular in shape), firm uterine contractions, and appearance of placenta in the vaginal opening. The nurse should utilize controlled cord traction technique for placental expulsion and coach in relaxation for delivery of the placenta. The nurse should not congratulate the patient on the delivery of her baby at this point (option a).
Option (b) is also incorrect because asking whether the placenta is important and encouraging skin-to-skin contact are not the appropriate actions for this stage of labor. Option (d) is incorrect because the nurse should monitor for excessive bleeding during the immediate postpartum period, not during the third stage of labor, and the use of absorbable synthetic suture materials for repair of perineal lacerations is not relevant to this stage of labor.
The controlled cord traction technique involves gentle traction on the umbilical cord while applying counterpressure to the uterus to deliver the placenta. This technique can reduce the risk of postpartum hemorrhage and ensure complete delivery of the placenta. The nurse should also coach the patient in relaxation techniques during this stage of labor to promote effective uterine contractions and facilitate the delivery of the placenta.
The nurse should administer prophylactic oxytocin as ordered to reduce the risk of postpartum hemorrhage. In addition, the nurse should perform primary repair of episiotomy or perineal lacerations using absorbable synthetic suture materials, as they have been shown to have fewer complications compared to chromic catgut. The immediate postpartum period is the most critical period for the mother, and the nurse should monitor for excessive bleeding and signs of infection. The nurse should also provide education on breastfeeding, ambulation, and newborn care during this period.
Question 15.
You are babysitting an infant when they start choking on a small toy. What should you do?
(a) Lay the infant on their back and perform abdominal thrusts.
(b) Give the infant water to drink to wash down the object.
(c) Hold the infant face down on your forearm and deliver back slaps and chest thrusts.
(d) Call 911 immediately and wait for paramedics to arrive.
Answer:
(c) Hold the infant face down on your forearm and deliver back slaps and chest thrusts.
Explanation:
When an infant is choking, the first thing you should do is hold them face down on your forearm with the head lower than the chest while resting on your forearm. You should then deliver up to 5 back slaps between the infant's shoulder blades using the heel of the other hand with sufficient force. If the object is still lodged, place your free hand on the infant's back while supporting the back of the infant's head with the palm of the hand. Cradle the infant between the two forearms and turn the infant as a unit while supporting the head and neck.
Then, rest the forearm on the thigh while holding the infant face up and deliver up to 5 chest thrusts in the middle of the chest over the lower half of the sternum at a rate of 1 per second with enough force to dislodge the foreign body. Repeat this sequence until the object is removed or the infant becomes unresponsive. If the infant becomes unresponsive, call for help and activate the emergency response system. Begin CPR while checking for a foreign body each time the airway is opened. Blind finger sweeps should not be performed, as this may push the foreign body further back into the airway.
Choking is a common emergency situation that can occur when an object becomes lodged in the throat or airway, obstructing the flow of air to the lungs. Infants and young children are particularly vulnerable to choking because they tend to put objects in their mouths. It is important to remain calm and act quickly if an infant is choking, as this can be a life-threatening situation. In addition to the steps outlined in the case study, it is important to seek medical attention for the infant after the object has been dislodged to ensure that there are no further complications.
Question 16.
A 32-year-old pregnant woman, at 38 weeks of gestation, presents to the labor and delivery unit with umbilical cord prolapse. Which of the following nursing interventions should be the nurse's first priority?
(a) Administer oxygen, 8 to 10 L/ minute, by face mask to the client.
(b) Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand.
(c) Prepare for immediate birth.
(d) Monitor fetal heart rate and assess the fetus for hypoxia.
Answer:
(b) Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand.
Explanation:
Umbilical cord prolapse is a medical emergency that requires immediate intervention to prevent fetal hypoxia and death. The nurse's first priority should be to relieve pressure on the cord. The nurse can relieve cord pressure by elevating the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand. The nurse should quickly glove the hand and insert two fingers into the vagina to the cervix and exert upward pressure on the presenting part. This maneuver will help to relieve pressure on the cord, ensuring adequate oxygenation of the fetus.
Option (a) Administer oxygen. 8 to 10 L/ minute, by face mask to the client: Although oxygen administration is an essential intervention, it should be performed after relieving cord pressure to ensure that the fetus is receiving adequate oxygenation.
Option (c) Prepare for immediate birth: Preparing for immediate birth is important, but it should be performed after the initial interv ention of relieving cord pressure.
Option (d) Monitor fetal heart rate and assess the fetus for hypoxia: Monitoring fetal heart rate and assessing the fetus for hypoxia are important interventions but should be performed after relieving cord pressure to ensure that the fetus is receiving adequate oxygenation.
Question 17.
A pregnant client with severe preeclampsia develops seizures. The nurse's immediate intervention should include:
(a) Administering pain medication
(b) Placing the client in a supine position
(c) Turning the client on her side and administering oxygen by face mask
(d) Administering oxytocin to induce labor
Answer:
(c) Turning the client on her side and administering oxygen by face mask
Explanation:
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, most commonly the liver and kidneys. It typically occurs after 20 weeks of gestation and can progress rapidly to eclampsia, which is associated with seizures, cerebral hemorrhage, and maternal and fetal death. Preeclampsia can be asymptomatic or present with symptoms such as headaches, visual disturbances, nausea, and edema.
Management of preeclampsia includes close monitoring of blood pressure, urine protein levels, and fetal well-being, as well as medications such as antihypertensives and magnesium sulfate to prevent seizures. The only definitive treatment for preeclampsia is delivery of the ferns and placenta, but this must be balanced against the risks of preterm delivery.
Seizures in a pregnant client with severe preeclampsia indicate the occurrence of eclampsia, which is a medical emergency requiring immediate intervention. The nurse should remain with the client and call for help, ensuring an open airway and turning the client on her side. This position helps to prevent aspiration and permits greater circulation through the placenta. The nurse should administer oxygen by face mask at 8 to 10 L/ minute to ensure adequate placental oxygenation.
Pain medication is not appropriate as it does not address the underlying cause of the seizures. Placing the client in a supine position is contraindicated as it can compromise blood flow to the fetus. Administering oxytocin to induce labor is not appropriate until the client is stabilized and the fetus is deemed to be in a safe condition. The nurse should monitor fetal heart rate patterns closely and administer medications as prescribed, such as magnesium sulfate, which can help to prevent further seizures.
After the seizure has ended, the nurse should insert an oral airway to maintain airway patency and suction the client’s mouth as needed. If warranted, the nurse should prepare for the delivery of the fetus after stabilization of the client. The nurse should document the occurrence, the client’s response, and the outcome.
Question 18.
A pregnant client arrives at the hospital with umbilical cord prolapse. The nurse takes immediate action to relieve cord pressure and provide appropriate care. Which of the following actions are appropriate for the nurse to take?
(a) Administer pain medication to the client
(b) Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand
(c) Push the cord into the uterus
(d) Place the client in a prone position
Answer:
(b) Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand
Explanation:
Umbilical cord prolapse is a medical emergency that occurs when the cord is lying alongside or below the presenting part of the fetus and can be seen or felt in or protruding from the vagina. In this situation, the nurse must relieve cord pressure immediately so that the fetus receives adequate oxygenation. Elevating the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand is an appropriate action that can relieve cord
pressure.
Administering pain medication to the client (Option a) is not a priority in this situation, and it does not address the emergency. Pushing the cord into the uterus (Option c) is also not appropriate because it can cause cord compression and decrease blood flow to the fetus. Placing the client in a prone position (Option d) is not recommended as it may increase cord compression and worsen the condition. Therefore, the correct answer is (b).
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