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A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
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The nurse is caring for a pregnant patient who is 34 weeks gestation and is concerned about the safety of using herbal remedies. What is the nurse's most appropriate response?
- A. Herbal remedies are always safe during pregnancy as long as they are natural.
- B. You should avoid all herbal remedies during pregnancy without consulting your healthcare provider.
- C. Herbal remedies are only unsafe during the first trimester of pregnancy.
- D. Herbal remedies are safe as long as they are purchased from a reputable source.
Correct Answer: B
Rationale: The correct answer is B because pregnant patients should avoid all herbal remedies without consulting their healthcare provider. During pregnancy, there can be potential risks associated with herbal remedies, as their safety and efficacy are not well studied. It is crucial for healthcare providers to assess the individual patient's medical history and current health status before recommending any herbal remedies.
Choice A is incorrect because not all herbal remedies are safe during pregnancy, regardless of being natural. Choice C is incorrect because herbal remedies can pose risks throughout pregnancy, not just in the first trimester. Choice D is incorrect because the safety of herbal remedies cannot be guaranteed solely by purchasing them from a reputable source. Consulting a healthcare provider is essential to ensure the safety of both the mother and the baby.
A woman in labor who is receiving oxytocin starts to experience uterine hyperstimulation. What should the nurse do first?
- A. Stop the oxytocin infusion
- B. Administer a tocolytic agent
- C. Increase the oxytocin infusion rate
- D. Position the patient on her left side
Correct Answer: A
Rationale: The correct answer is A: Stop the oxytocin infusion. Uterine hyperstimulation can lead to fetal distress and compromise maternal and fetal well-being. Stopping the oxytocin infusion is the first step to prevent further complications. Administering a tocolytic agent (B) is not the initial action for uterine hyperstimulation. Increasing the oxytocin infusion rate (C) would exacerbate the hyperstimulation. Positioning the patient on her left side (D) can help improve blood flow but is not the priority in this situation.
A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most appropriate nursing intervention?
- A. Encourage ambulation
- B. Apply compression stockings
- C. Administer low-molecular-weight heparin
- D. Monitor for signs of edema
Correct Answer: B
Rationale: The correct answer is B: Apply compression stockings. This intervention is appropriate for a postpartum person at risk for DVT as it helps promote circulation and prevent blood clots by applying pressure to the legs. Compression stockings are a safe and non-invasive method to reduce the risk of DVT. Encouraging ambulation (choice A) is important but may not be feasible immediately postpartum. Administering low-molecular-weight heparin (choice C) would require a prescription and may not be the first-line intervention. Monitoring for signs of edema (choice D) is important but does not directly address the prevention of DVT like compression stockings do.
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
- A. The nurse midwife saw that the mucous plug was intact.
- B. The nurse midwife felt the baby rebound after being pushed.
- C. The nurse midwife palpated the fetal parts through the uterine wall.
- D. The nurse midwife assessed that the baby is head down.
Correct Answer: B
Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.
A pregnant woman who is 20 weeks gestation asks about the risk of consuming caffeine during pregnancy. Which of the following responses is most appropriate?
- A. It is safe to consume up to 200 mg of caffeine per day during pregnancy.
- B. You should avoid caffeine completely during pregnancy.
- C. Moderate caffeine consumption is okay, but avoid drinking coffee in the afternoon.
- D. Caffeine has no impact on your pregnancy, so you can drink it as desired.
Correct Answer: A
Rationale: The correct answer is A because current guidelines suggest that consuming up to 200 mg of caffeine per day is considered safe during pregnancy. This amount is unlikely to harm the developing fetus. Excessive caffeine intake has been associated with an increased risk of miscarriage and low birth weight.
Option B is incorrect as complete avoidance of caffeine is not necessary, but rather moderation is key. Option C is partially correct in emphasizing moderation but the recommendation to avoid coffee in the afternoon is not supported by evidence. Option D is incorrect as caffeine does have an impact on pregnancy, and unrestricted consumption is not advisable.