Nokea
A woman had a miscarriage at 12 weeks' gestation and had D&C,
- A. While you are assessing her response to loss, she tells you she had
- B. Based on your assessment what nursing intervention would you use first?
- C. You ask her what items she bought for the baby
Correct Answer: B
Rationale: The correct answer is B because the priority in nursing care after a miscarriage and D&C is to assess the woman's physical and emotional well-being. By using the nursing intervention of assessment first, the nurse can determine any immediate needs for pain management, emotional support, or further medical intervention. This helps in providing individualized care and addressing any potential complications promptly.
Choice A is incorrect because assessing her response to loss comes after ensuring her immediate physical and emotional needs are met. Choice C is incorrect as it focuses on material items rather than the woman's well-being. Choice D is incomplete and does not provide a viable option for nursing intervention.
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The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.
What should health-care providers be attentive to during the trauma-informed gynecologic examination to avoid retraumatization? Select all that apply.
- A. providing information about trauma support resources
- B. establishing safety and trust
- C. recognizing signs of distress and offering support
- D. using trauma-sensitive language and communication
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D.
B: Establishing safety and trust is crucial to avoid retraumatization during the examination. It helps create a secure environment for the patient.
C: Recognizing signs of distress and offering support shows empathy and helps address any emotional reactions that may arise during the examination.
D: Using trauma-sensitive language and communication is essential to avoid triggering past traumas and ensuring clear and respectful communication.
Choices A is incorrect because while providing information about trauma support resources is important, it is not directly related to avoiding retraumatization during the examination.
As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
The nurse is educating a prenatal client about weight dysphoric disorder. Which statement by the client gain during pregnancy. Which statement by the would require immediate follow-up? client indicates effective understanding?
- A. I have been crying the week of my period.
- B. I should gain 2 to 4 pounds in the first trimester
- C. I am experiencing suicidal thoughts. and half a pound per week in the last two
- D. My menstrual cycle is 1 week late. trimesters.
Correct Answer: C
Rationale: Correct Answer: C. "I am experiencing suicidal thoughts."
Rationale: This statement indicates a serious mental health concern that requires immediate follow-up. Suicidal thoughts during pregnancy can be a sign of depression or other mental health issues that need to be addressed promptly to ensure the safety and well-being of the client and the baby.
Summary of Other Choices:
A: "I have been crying the week of my period." - This statement suggests premenstrual symptoms which are common and not necessarily alarming during pregnancy.
B: "I should gain 2 to 4 pounds in the first trimester and half a pound per week in the last two trimesters." - This statement reflects a correct understanding of weight gain recommendations during pregnancy and does not raise immediate concerns.
D: "My menstrual cycle is 1 week late." - This statement is not concerning during pregnancy as menstrual cycles typically stop during pregnancy.
The nurse is educating a client about gestational diabetes. What is the most important teaching point?
- A. Avoid all carbohydrates.
- B. Check your blood sugar only when symptomatic.
- C. Monitor blood sugar regularly as prescribed.
- D. Increase your physical activity significantly.
Correct Answer: C
Rationale: The correct answer is C: Monitor blood sugar regularly as prescribed. This is crucial in managing gestational diabetes to ensure blood sugar levels are within target range, preventing complications for both mother and baby. Regular monitoring helps track the effectiveness of treatment and dietary adjustments. Avoiding all carbohydrates (A) is not recommended as some are necessary for energy. Checking blood sugar only when symptomatic (B) is insufficient as it may miss important fluctuations. Increasing physical activity significantly (D) is beneficial but not the most important teaching point compared to consistent blood sugar monitoring.