Nokea
A nurse is educating a birthing person about the benefits of skin-to-skin contact with their newborn immediately after birth. The nurse explains that this practice has numerous advantages. Which of the following benefits is NOT typically associated with skin-to-skin contact?
- A. improved bonding between parent and baby
- B. enhanced thermoregulation for the newborn
- C. decreased risk of neonatal infections
- D. accelerated uterine involution for the birthing person
Correct Answer: D
Rationale: The correct answer is D: accelerated uterine involution for the birthing person. Skin-to-skin contact does not directly impact the process of uterine involution. The benefits of skin-to-skin contact include improved bonding (A), enhanced thermoregulation (B), and decreased risk of neonatal infections (C). These benefits are well-documented and supported by research. In contrast, uterine involution is a physiological process that occurs naturally postpartum and is not influenced by skin-to-skin contact. Therefore, choice D is the correct answer in this scenario.
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A pregnant patient at 36 weeks gestation is experiencing swelling in her hands and feet. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Instruct the patient to rest and elevate her legs regularly.
- C. Advise the patient to drink more water and reduce sodium intake.
- D. Encourage the patient to take a warm bath to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A. At 36 weeks gestation, swelling in the hands and feet could be a sign of preeclampsia, a serious condition. The nurse's priority is to monitor the patient's blood pressure and assess for other signs of preeclampsia, such as headache, visual disturbances, and proteinuria. Prompt detection and management of preeclampsia are crucial to prevent complications like eclampsia and HELLP syndrome. Choices B, C, and D do not address the potential seriousness of the situation and may delay the necessary assessment and intervention for preeclampsia.
The nurse is caring for a pregnant patient who is 30 weeks gestation and reports feeling faint and lightheaded. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to lie on her back to improve circulation.
- B. Encourage the patient to take deep breaths and sit down immediately.
- C. Instruct the patient to stand up slowly and rest for 10 minutes.
- D. Ask the patient to eat something sweet to raise her blood sugar.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to take deep breaths and sit down immediately. This action is appropriate because the patient is experiencing symptoms of hypotension, which can lead to decreased blood flow to the brain causing faintness and lightheadedness. By encouraging the patient to take deep breaths and sit down immediately, the nurse is helping to increase oxygen intake and improve circulation, which can alleviate the symptoms.
Explanation for why the other choices are incorrect:
A: Instructing the patient to lie on her back can actually worsen symptoms as it can lead to a decrease in blood flow to the brain.
C: Instructing the patient to stand up slowly is not appropriate as the patient is already feeling faint and lightheaded. This can increase the risk of falling and injury.
D: Asking the patient to eat something sweet may not address the underlying cause of the symptoms, which is likely related to hypotension. It is important to address the immediate
A woman in labor begins to experience uterine rupture. What is the most important intervention?
- A. Administer pain relief medication
- B. Prepare for an emergency cesarean section
- C. Administer oxygen to the mother
- D. Increase the IV fluid rate
Correct Answer: B
Rationale: The correct answer is B: Prepare for an emergency cesarean section. Uterine rupture during labor is a life-threatening emergency requiring immediate surgical intervention to prevent catastrophic outcomes for both the mother and the baby. A cesarean section is the most effective and timely intervention to address the uterine rupture and ensure the safety of both individuals. Administering pain relief medication (A) may be necessary but is not the most urgent intervention. Administering oxygen to the mother (C) can help with oxygenation, but it does not address the underlying issue of uterine rupture. Increasing IV fluid rate (D) may be helpful in some situations but is not the primary intervention needed to manage uterine rupture.
A pregnant patient is 26 weeks gestation and reports difficulty breathing when lying flat. What should the nurse recommend?
- A. Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm.
- B. Recommend sleeping in a fully reclined position to prevent shortness of breath.
- C. Administer oxygen as prescribed to ensure proper oxygenation.
- D. Instruct the patient to lie flat on her back and use a pillow for support.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm. At 26 weeks gestation, the uterus can compress the inferior vena cava when lying flat on the back, leading to decreased blood return to the heart and reduced cardiac output, causing difficulty breathing. Sleeping on the left side helps improve circulation by reducing pressure on the vena cava, enhancing blood flow and oxygenation to the fetus and mother.
Incorrect options:
B: Recommending sleeping in a fully reclined position may not alleviate the compression on the vena cava and could potentially worsen the patient's symptoms.
C: Administering oxygen may help with oxygenation but does not address the underlying issue of vena cava compression due to the growing uterus.
D: Instructing the patient to lie flat on her back can exacerbate the issue by further compressing the vena cava, worsening breathing difficulties.
A woman in labor requests an epidural. What should the nurse assess before administering the epidural?
- A. Cervical dilation
- B. Maternal blood pressure
- C. Fetal heart rate
- D. Maternal temperature
Correct Answer: B
Rationale: The correct answer is B: Maternal blood pressure. Before administering an epidural, it is crucial to assess the maternal blood pressure to ensure it is within the normal range. Hypotension can occur as a common side effect of epidural anesthesia, which can lead to decreased placental perfusion and compromise fetal oxygenation. Assessing maternal blood pressure helps in preventing potential complications.
Incorrect choices:
A: Cervical dilation - Not directly related to the administration of an epidural.
C: Fetal heart rate - Important but not the immediate assessment needed before administering an epidural.
D: Maternal temperature - While it is important in general assessment, it is not specifically required before giving an epidural.