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A patient in labor begins to experience significant vaginal bleeding. What is the first step the nurse should take?
- A. Administer oxygen to the patient
- B. Check for a cord prolapse
- C. Perform a vaginal examination
- D. Perform a vaginal examination
Correct Answer: B
Rationale: The correct answer is B: Check for a cord prolapse. This is the first step because cord prolapse is a critical emergency that can lead to fetal compromise. By checking for cord prolapse, the nurse can quickly assess the situation and take appropriate actions to relieve pressure on the cord. Administering oxygen (choice A) may be necessary later but not the first step. Performing a vaginal examination (choices C and D) can exacerbate the situation by pushing the cord further into the birth canal.
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A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. When is the best time for the nurse to schedule the patient’s ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: An ultrasound at around 5-6 weeks after the last menstrual period is the most accurate time to determine gestational age.
A nurse is caring for a laboring person who is receiving oxytocin for labor induction. What is the priority intervention when uterine hyperstimulation occurs?
- A. stop the oxytocin infusion
- B. increase the oxytocin infusion
- C. administer IV fluids
- D. administer an epidural
Correct Answer: D
Rationale: The correct answer is D: administer an epidural. Uterine hyperstimulation during labor can lead to fetal distress and complications. Administering an epidural can help manage pain and relax the uterus, reducing the risk of hyperstimulation. Stopping the oxytocin infusion (choice A) is also important, but managing the uterine contractions with an epidural takes priority. Increasing the oxytocin infusion (choice B) would exacerbate the hyperstimulation. Administering IV fluids (choice C) may be helpful, but it does not directly address the uterine hyperstimulation.
A pregnant patient is at 34 weeks gestation and reports persistent lower back pain and difficulty sleeping. What is the nurse's best recommendation for this patient?
- A. Rest in bed and avoid any physical activity.
- B. Use a firm mattress and avoid sleeping on the back.
- C. Take over-the-counter pain medications to alleviate symptoms.
- D. Apply heat to the back and practice good posture while sitting.
Correct Answer: B
Rationale: The correct answer is B: Use a firm mattress and avoid sleeping on the back. This recommendation is appropriate because during pregnancy, the weight of the uterus can compress blood vessels when lying on the back, causing back pain and affecting circulation. Using a firm mattress can provide better support for the back, relieving discomfort. Avoiding sleeping on the back reduces the risk of decreased blood flow to the fetus.
A: Rest in bed and avoid any physical activity is incorrect because it can lead to muscle stiffness and worsen back pain.
C: Taking over-the-counter pain medications may provide temporary relief but does not address the root cause of the discomfort.
D: Applying heat to the back and practicing good posture are helpful strategies, but avoiding sleeping on the back is more crucial to alleviate the symptoms in this case.
Which is equivalent to a 2 oz protein serving?
- A. 4 tbsp peanut butter
- B. 2 eggs
- C. 1 cup cooked lima beans
- D. 2 ounces mixed nuts
Correct Answer: B
Rationale: Two eggs are equivalent to a 2 oz protein serving, providing approximately 12 grams of protein.
The nurse is assessing a pregnant patient in the second trimester who is complaining of leg cramps. Which of the following interventions is most appropriate?
- A. Encourage the patient to take a hot bath to relieve the cramps.
- B. Instruct the patient to elevate her legs while resting.
- C. Recommend regular stretching exercises to prevent cramps.
- D. Suggest that the patient take calcium supplements to prevent cramps.
Correct Answer: B
Rationale: The correct answer is B. Elevating her legs while resting helps improve circulation and reduce the risk of leg cramps in pregnant patients. This position promotes blood flow and reduces the pressure on the blood vessels. Choices A and D do not directly address improving circulation or reducing pressure on blood vessels. Choice C, while beneficial in general, may not provide immediate relief for the current leg cramps. Therefore, elevating the legs while resting is the most appropriate intervention for the pregnant patient experiencing leg cramps in the second trimester.