[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-113-1-maternal-pediatric-007":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":34,"lastmod":63},"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-113-1-產兒科護理學-007","nurse-113-1-maternal-pediatric-007",113,1,7,"葉女士，28歲，G1P0，待產過程中突然自然破水，內診發現子宮頸口開8公分、變薄程度80%、先露部位+1。下列何者為最優先之護理處置？",{"A":14,"B":15,"C":16,"D":17},"提供灌腸","監測胎心率變化","提供氧氣","採平躺增加子宮血流","B",null,[],"本題考點在於突然自然破水後、產程進展至第一產程末的護理優先順序。此案例子宮頸口開 8 公分、變薄 80%、先露部位 +1，屬活動期末段（過渡期），破水後最大風險是臍帶脫垂與胎兒窘迫，故最優先為 B「監測胎心率變化」，以即時偵測是否出現變異性減速等臍帶受壓徵象。A「灌腸」不當，在過渡期且近生產不宜灌腸。C「提供氧氣」為胎心異常時的後續措施，須先評估胎心才知是否需要，非最優先。D「平躺增加子宮血流」錯誤，平躺可能誘發仰臥低血壓症候群反而減少胎盤灌流，且此選項未針對破水後首要風險。故正解為 B。","臨床邏輯延伸：任何破水（尤其胎頭未完全固定或高位破水）後，護理首要是聽胎心並觀察羊水性狀，因臍帶可能隨羊水沖出而脫垂，導致臍帶受壓、胎兒急性缺氧。評估（assessment）先於處置（intervention）是護理優先順序的通則——先確認胎兒安危，才決定給氧、改變體位或通知醫師。若胎心確有異常，處置順序常為左側臥、給氧、停催產素、靜脈輸液擴容並準備可能的緊急剖腹。可連結胎心監測判讀（早期、變異性、晚期減速的意義）。",[24,27,30,32],{"term":25,"count":26},"第一產程過渡期",4,{"term":28,"count":29},"破水後臍帶脫垂風險",2,{"term":31,"count":10},"胎心率監測優先",{"term":33,"count":10},"評估先於處置",[35,39,43,48,53,58],{"webId":36,"stem":37,"number":38,"year":9,"session":10},"nurse-113-1-maternal-pediatric-008","陰道生產過程，下列何種情形表示先露部位胎頭已發生著冠（crowning）？",8,{"webId":40,"stem":41,"number":26,"year":9,"session":42},"nurse-113-3-maternal-pediatric-004","王女士，懷孕 16 週，有關產檢報告結果，下列何者需最優先給予衛教？",3,{"webId":44,"stem":45,"number":46,"year":47,"session":10},"nurse-114-1-maternal-pediatric-048","芷妹，9歲，因頭痛、發燒就醫，診斷為病毒性腦膜炎（virus meningitis）入院治療，有關此疾病相關症狀和治療，下列敘述何者錯誤？",48,114,{"webId":49,"stem":50,"number":51,"year":52,"session":29},"nurse-115-2-maternal-pediatric-046","小金，5 個月大，罹患甲狀腺功能低下症，目前接受 L-thyroxine 治療，有關小金的居家照護，下列敘述何者錯誤？",46,115,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-107-1-maternal-pediatric-040","有關急性骨盆腔炎婦女的照護措施，下列何者錯誤？",40,107,{"webId":59,"stem":60,"number":61,"year":62,"session":10},"nurse-108-1-maternal-pediatric-074","新生兒篩檢為半乳糖血症陽性之飲食原則，下列何者錯誤？",74,108,"2026-09-04",1788510750706]