What should the nurse do if a laboring woman becomes light-headed and tachypneic?

Correct Answer: B

Rationale: If a laboring woman becomes light-headed and tachypneic, it is essential for the nurse to address the potential hyperventilation that may be causing these symptoms. Choice A: Checking the blood pressure is not the most appropriate action in this situation. While it is important to monitor blood pressure during labor, it is not the priority when a woman is experiencing light-headedness and tachypnea. Choice C: Moving the woman to her side is a common intervention for improving blood flow and oxygenation to the fetus, but it does not directly address the woman's symptoms of light-headedness and tachypnea. Choice D: Assessing the fetal heart rate is important during labor, but it is not the priority when the woman is experiencing symptoms that suggest hyperventilation. The correct answer is B: Having the woman rebreathe her exhalations. This technique helps to increase her carbon dioxide levels and decrease her respiratory rate, addressing the underlying cause of her symptoms. By having the woman rebreathe her exhalations, the nurse can help restore the balance of oxygen and carbon dioxide in her body, alleviating her light-headedness and tachypnea.

Correct Answer: A

Rationale: Average variability in fetal heart tracing indicates that the baby's heart rate is fluctuating within the normal range, which is a positive sign of fetal well-being. In this case, no intervention is needed (Choice A). Administering oxygen (Choice B) would be unnecessary and potentially harmful as there is no indication of fetal distress. Changing the client's position (Choice C) may be helpful in cases of decreased variability, but in the case of average variability, it is not required. Increasing IV fluids (Choice D) would not have any impact on fetal heart rate variability and is not indicated in this situation. Therefore, the correct answer is A: No intervention needed, as average variability is a reassuring finding in fetal monitoring.

Correct Answer: C

Rationale: In the case of a fetus in sacral presentation with the back towards the mother's right side, the correct placement for the fetal monitor is the right upper quadrant. This is because the fetal heart rate is best detected when the monitor is placed on the side of the fetal back, which is closer to the mother's right side in this scenario. Choice A (Left upper quadrant) is incorrect because placing the monitor on the left side would be farther away from the fetal back, making it more difficult to detect the fetal heart rate accurately. Choice B (Left lower quadrant) is also incorrect because this area is typically where the mother's own heart rate is most prominent, which could interfere with the accurate detection of the fetal heart rate. Choice D (Right lower quadrant) is incorrect because placing the monitor on the lower quadrant would not be ideal for detecting the fetal heart rate, as it is closer to the maternal pelvic region rather than the fetal back. In conclusion, the correct placement of the fetal monitor in the right upper quadrant allows for the most accurate detection of the fetal heart rate in the scenario of a fetus in sacral presentation with the back towards the mother's right side.

Correct Answer: B

Rationale: Rupture of membranes is the correct answer because it indicates that the amniotic sac has broken, leading to leakage of amniotic fluid. This is a sign that labor may be starting, and it is crucial for the pregnant woman to seek medical attention to ensure the safety of both herself and the baby. This situation can lead to complications if not managed properly, such as infection or umbilical cord prolapse. Back pain (choice A) is a common symptom during pregnancy and is not necessarily a reason to go to the hospital unless it is severe, persistent, or accompanied by other concerning symptoms such as bleeding or contractions. It could be due to the normal changes in the body during pregnancy or musculoskeletal issues. Expulsion of the mucus plug (choice C) is also a common occurrence as the body prepares for labor, but it is not a definitive sign that labor is imminent. It can regenerate or be expelled weeks before labor starts, so it is not a reliable indicator to prompt a hospital visit. Greenish fluid leakage (choice D) could indicate meconium-stained amniotic fluid, which may be a sign of fetal distress. However, it is not as urgent as rupture of membranes because it does not always mean immediate danger. It is still important to seek medical attention, but it is not as time-sensitive as a rupture of membranes.

Correct Answer: D

Rationale: To determine the frequency and duration of contractions occurring every 3 minutes and lasting 60 seconds, we need to break down each part of the question. First, let's address the frequency of contractions. The question states that the contractions are occurring every 3 minutes. This means that the time interval between each contraction is 3 minutes. Now, let's move on to the duration of the contractions. The question states that each contraction lasts 60 seconds. This means that the duration of each contraction is 60 seconds. Therefore, the correct answer is D: every 3 minutes and lasting 60 seconds. This choice accurately reflects the information provided in the question. Now, let's analyze the incorrect answer choices: A: q 2 min 60 sec - This choice states that the contractions occur every 2 minutes and last 60 seconds. However, the question specifies that the contractions occur every 3 minutes, so this choice is incorrect. B: q 4 min 120 sec - This choice states that the contractions occur every 4 minutes and last 120 seconds. Again, this does not align with the information provided in the question, making this choice incorrect. C: q 3 min 120 sec - This choice states that the contractions occur every 3 minutes and last 120 seconds. However, the question specifies that each contraction lasts 60 seconds, not 120 seconds. Therefore, this choice is also incorrect. In conclusion, the correct answer is D because it accurately reflects the information provided in the question regarding the frequency and duration of the contractions. Choices A, B, and C are incorrect as they do not align with the information given in the question.