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A nurse is caring for a laboring person who has been pushing for several hours without progress. What is the most appropriate intervention?
- A. perform a cesarean section
- B. assist with vacuum extraction
- C. perform an emergency cesarean
- D. assist with forceps delivery
Correct Answer: B
Rationale: The correct answer is B: assist with vacuum extraction. This intervention is appropriate when prolonged pushing has not resulted in progress during labor. Vacuum extraction helps facilitate the delivery of the baby by applying suction to the baby's head to assist with pulling them out. It is less invasive than a cesarean section and forceps delivery, making it a safer option in this scenario. Performing a cesarean section (choices A and C) would be considered if vacuum extraction is unsuccessful or contraindicated due to specific factors. Forceps delivery (choice D) is another option but is generally considered more invasive and carries higher risks compared to vacuum extraction.
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A pregnant patient at 28 weeks gestation expresses concern about her baby's movements. Which of the following should the nurse recommend?
- A. Count fetal movements and report a decrease of more than 10 movements per day.
- B. Wait until after 32 weeks to worry about fetal movement.
- C. Do not count fetal movements and only report if you notice pain.
- D. Always lie down and count fetal movements after meals.
Correct Answer: A
Rationale: The correct answer is A: Count fetal movements and report a decrease of more than 10 movements per day. This recommendation is evidence-based and aligns with guidelines for monitoring fetal well-being. Counting fetal movements helps assess fetal health, and a decrease in movements could indicate potential issues like fetal distress. Reporting a decrease of more than 10 movements per day ensures timely intervention if needed.
Choice B is incorrect because waiting until after 32 weeks could delay necessary intervention if there are concerns about fetal movements. Choice C is incorrect as it dismisses the importance of monitoring fetal movements altogether. Choice D is incorrect as there is no requirement to always lie down or restrict monitoring to only after meals, which could lead to missed opportunities for detecting potential problems.
A pregnant patient has received the results of her triple-screen testing and it is positive. What would the nurse anticipate as the next step in the patient’s plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: A positive triple-screen test suggests an increased risk of genetic abnormalities, requiring additional diagnostic testing.
During a prenatal visit, a gravid client is complaining of ptyalism. Which of the following nursing interventions is appropriate?
- A. Encourage the woman to brush her teeth carefully.
- B. Advise the woman to have her blood pressure checked regularly.
- C. Encourage the woman to wear supportive hosiery.
- D. Advise the woman to avoid eating rare meat.
Correct Answer: A
Rationale: Ptyalism (excessive salivation) can lead to oral hygiene issues, so encouraging careful tooth brushing is appropriate. Blood pressure checks, wearing supportive hosiery, and avoiding rare meat address other concerns but are unrelated to ptyalism.
A nurse is caring for a postpartum person who is experiencing a headache. What is the most likely cause of a postpartum headache?
- A. Eclampsia
- B. Spinal headache
- C. Tension headache
- D. Cluster headache
Correct Answer: B
Rationale: The correct answer is B: Spinal headache. Postpartum spinal headaches are commonly caused by leakage of cerebrospinal fluid due to accidental dural puncture during epidural anesthesia. This can lead to severe headaches that worsen when sitting or standing. Eclampsia (A) presents with hypertension and seizures, not just headaches. Tension headaches (C) are typically stress-related and not specific to the postpartum period. Cluster headaches (D) are characterized by severe pain around the eye and are not commonly associated with childbirth.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and is experiencing a sudden increase in vaginal discharge. What is the nurse's priority action?
- A. Check for signs of labor and assess fetal heart rate.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Perform a pelvic exam to assess the amount of discharge.
- D. Call the healthcare provider immediately to report the change in discharge.
Correct Answer: A
Rationale: The correct answer is A because the sudden increase in vaginal discharge at 40 weeks gestation could indicate the onset of labor. Checking for signs of labor, such as contractions and assessing fetal heart rate, is crucial to determine if the patient is in active labor. This helps in timely intervention and ensuring the well-being of both the mother and baby.
Summary:
- Choice B: Encouraging rest and monitoring changes in discharge may not address the urgency of the situation.
- Choice C: Performing a pelvic exam without assessing signs of labor or fetal well-being may delay necessary actions.
- Choice D: While reporting to the healthcare provider is important, immediate assessment of labor signs and fetal heart rate takes precedence.