A 40-year-old primiparous woman who is 38 weeks pregnant has been on the labor unit for an hour when she starts to complain of feeling dizzy, light-headed, and nauseous. Her blood pressure is 90/60. What should be the first response of the nurse?

Correct Answer: B

Rationale: The correct answer is B: Turn the patient to her left side. Rationale: 1. The patient's symptoms of dizziness, light-headedness, and low blood pressure (90/60) suggest hypotension, which could be due to supine hypotensive syndrome in pregnancy. 2. Turning the patient to her left side can help alleviate pressure on the vena cava, improving blood flow back to the heart and subsequently increasing blood pressure. 3. This immediate action can help prevent further complications such as decreased placental perfusion and fetal distress. Summary: - Choice A (Give the patient a bolus of intravenous fluid): While IV fluids may be needed, the priority is to address the underlying cause of hypotension first. - Choice C (Call the obstetrician or nurse midwife): While it is important to involve the healthcare provider, immediate action to address the hypotension is crucial. - Choice D (Give the patient an antiemetic medication for

Correct Answer: A

Rationale: The correct answer is A: Preeclampsia. In this scenario, the sudden onset of severe headache and blurry vision in a pregnant woman in labor are indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and signs of organ damage. The nurse should assess for other symptoms of preeclampsia such as hypertension, proteinuria, edema, and epigastric pain. Preeclampsia can lead to eclampsia, seizures, and life-threatening complications for both the mother and the baby if not promptly managed. Summary: B: Fetal distress - Not the priority assessment when the mother is experiencing symptoms indicative of a serious maternal condition like preeclampsia. C: Uterine rupture - Symptoms are not suggestive of uterine rupture, which typically presents with severe abdominal pain, vaginal bleeding, and signs of shock. D: Placenta previa - Symptoms are not consistent with placenta previa, which typically

Correct Answer: B

Rationale: The correct answer is B: Hands and knees position. This position helps relieve back pain during labor by promoting optimal fetal positioning, reducing pressure on the back, and allowing gravity to assist in the descent of the baby. It also opens up the pelvic outlet, making it easier for the baby to navigate through the birth canal. Incorrect choices: A: Supine position can worsen back pain as it puts pressure on the lower back and restricts blood flow to the uterus. C: Lithotomy position can exacerbate back pain as it involves lying on the back with legs in stirrups, which can increase pressure on the back. D: Squatting position may not be ideal for relieving back pain in this scenario as it can put additional strain on the back muscles and may not provide optimal support for the laboring individual.

Correct Answer: B

Rationale: The correct answer is B: "You can have the epidural now since you are in active labor." At 6cm dilation, the patient is typically considered to be in active labor, making it an appropriate time to offer an epidural for pain relief. Administering the epidural at this stage can help manage the pain effectively and provide relief during the remainder of labor. Other choices are incorrect because waiting until 8cm dilation (Choice A) may cause unnecessary suffering, administering after the second stage (Choice C) is too late for pain relief, and giving it during the latent phase (Choice D) is not ideal as the patient may not be in active labor yet.

Correct Answer: C

Rationale: The correct answer is C: Assess the fetal heart rate. This is important to ensure the baby's well-being during the pushing phase. By monitoring the fetal heart rate, the nurse can detect any signs of distress or complications, allowing for prompt intervention if needed. Encouraging the patient to push (A) is appropriate once the fetal well-being is confirmed. While preparing the delivery room (B) is important, it is not the immediate priority. Administering pain relief (D) can be considered after assessing the fetal heart rate and ensuring the baby's safety.