[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-108-2-maternal-pediatric-010":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":62},"產兒科護理學","maternal-pediatric",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-108-2-產兒科護理學-010","nurse-108-2-maternal-pediatric-010",108,2,10,"李女士在第一產程中破水，下列何者為最優先的措施？",{"A":14,"B":15,"C":16,"D":17},"給予陰道內診","評估胎心音 1 分鐘","給予腹部觸診","以石蕊試紙測試羊水","B",null,[],"本題考點是第一產程破水後的優先護理措施。依破水後最急迫的風險為臍帶脫垂造成胎兒缺氧，故最優先須立即評估胎心音（至少聽診 1 分鐘），以判斷有無臍帶受壓所致的心跳下降，故選 B。A 陰道內診雖可評估產程，但破水後過度內診會增加上行性感染風險，且非最優先。C 腹部觸診用於評估胎位與宮縮，無法即時反映胎兒安危。D 以石蕊（硝嗪）試紙測試確認是否為羊水，屬確認破水性質的檢查，重要性次於先確保胎兒安全。判斷順序上，先護胎兒生命徵象再做其他評估。","破水後風險三連：臍帶脫垂（尤其胎頭未固定、羊水多、胎位不正時）、上行性感染、胎盤早期剝離。優先原則＝先評估胎兒（胎心音）再處理其他。臍帶脫垂典型胎心音為變異性或延遲性減速、甚至嚴重心搏過緩。硝嗪試紙遇鹼性羊水由黃轉藍（pH>6.5），配合羊齒狀結晶（ferning）確認破水。記憶：『破水第一件事——聽胎心，防的是臍帶脫垂』。",[24,27,30,32],{"term":25,"count":26},"臍帶脫垂",3,{"term":28,"count":29},"破水",1,{"term":31,"count":29},"胎心音評估",{"term":33,"count":29},"硝嗪試紙",[35,39,44,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-108-2-maternal-pediatric-011","王女士待產時，胎心率之變異性為 6～10 bpm，下列敘述何者正確？",11,{"webId":40,"stem":41,"number":42,"year":43,"session":29},"nurse-109-1-maternal-pediatric-027","糖尿病孕婦所產下體重過重的嬰兒（出生體重在 4,000 公克以上）容易在出生後發生低血糖的狀況，主要原因可能是：",27,109,{"webId":45,"stem":46,"number":47,"year":43,"session":10},"nurse-109-2-maternal-pediatric-041","小畢 3 歲，因為經常出現咬手、打頭、撞牆行為而就醫，醫師診斷有自閉症，護理師指導父母有關自閉症的兒童照護，下列何者錯誤？",41,{"webId":49,"stem":50,"number":51,"year":52,"session":10},"nurse-110-2-maternal-pediatric-079","陳小妹，於學校上體育課時，出現強直陣攣型痙攣（tonic-clonic seizure）發作，下列護理措施何者最不適當？",79,110,{"webId":54,"stem":55,"number":56,"year":57,"session":29},"nurse-112-1-maternal-pediatric-043","李小妹，2 歲 8 個月，屬於李小妹遊戲發展特點，下列敘述何者正確？",43,112,{"webId":59,"stem":60,"number":42,"year":61,"session":29},"nurse-113-1-maternal-pediatric-027","小明，16歲，高中一年級，在校成績低落、情緒不穩、易怒、缺課，曾表明想從世界消失。就醫後診斷為青少年憂鬱症。媽媽詢問護理師如何幫助小明時，下列敘述何者錯誤？",113,"2026-09-04",1788510706939]