Nokea
A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate?
- A. That is very exciting. The baby must be very healthy.
- B. Would you please describe what you felt for me?
- C. That is impossible. The baby is not big enough yet.
- D. Would you please let me see if I can feel the baby?
Correct Answer: B
Rationale: At 10 weeks, fetal movement is unlikely to be felt. The nurse should ask the client to describe what she felt to determine if it was indeed fetal movement or another sensation.
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Which of the following is true about the use of a birthing ball during labor?
- A. It is contraindicated for patients with high blood pressure
- B. It promotes pelvic mobility and can help reduce pain
- C. It should only be used during the second stage of labor
- D. It is only effective in early labor
Correct Answer: B
Rationale: The correct answer is B because a birthing ball promotes pelvic mobility, which can help reduce pain during labor by encouraging movement and optimal positioning of the baby. It is not contraindicated for patients with high blood pressure unless specifically advised by a healthcare provider. It can be used throughout labor, not just during the second stage, and is effective at various stages, not just in early labor.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during the pushing phase?
- A. assist the person into a squatting position
- B. instruct the person to push with contractions
- C. coach the person through controlled pushing
- D. prepare for spontaneous delivery
Correct Answer: D
Rationale: The correct answer is D: prepare for spontaneous delivery. During the pushing phase of the second stage of labor, the most appropriate nursing intervention is to prepare for the spontaneous delivery of the baby. This involves ensuring that all necessary equipment and supplies are ready for the delivery, positioning oneself appropriately to assist with the birth, and being prepared to provide immediate care to the newborn. This intervention is crucial to ensure a safe and smooth delivery process.
Choice A (assist the person into a squatting position) may not be appropriate for all laboring individuals and may not facilitate the most effective pushing efforts. Choice B (instruct the person to push with contractions) is a general instruction that may not encompass all the necessary aspects of supporting the delivery process. Choice C (coach the person through controlled pushing) may be too restrictive and not allow for the natural progression of labor. Thus, the most appropriate intervention is to prepare for spontaneous delivery to ensure readiness and safety for both the laboring person and the newborn.
The nurse is caring for a pregnant patient at 34 weeks gestation who is experiencing leg cramps. What is the most appropriate recommendation for the nurse to make?
- A. Increase calcium and vitamin D intake to prevent cramps.
- B. Encourage the patient to perform leg stretches and elevate the legs.
- C. Administer pain medications and apply ice to the affected areas.
- D. Recommend frequent walking to strengthen leg muscles.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to perform leg stretches and elevate the legs. Leg cramps are common in pregnancy due to increased pressure on nerves and blood vessels. Leg stretches help relieve muscle tension, and elevating the legs promotes circulation. Increasing calcium and vitamin D may be helpful but not the primary intervention. Administering pain medications and applying ice may provide temporary relief but do not address the underlying cause. Frequent walking can help strengthen leg muscles but may exacerbate cramps if done excessively.
The nurse has taken a health history on four primigravid clients at their first prenatal visits. It is high priority that which of the clients receives nutrition counseling?
- A. The woman diagnosed with phenylketonuria.
- B. The woman who has Graves’ disease.
- C. The woman with Cushing’s syndrome.
- D. The woman diagnosed with myasthenia gravis.
Correct Answer: A
Rationale: Phenylketonuria (PKU) requires strict dietary management, especially during pregnancy, to prevent harm to the fetus. The other conditions do not have the same immediate dietary implications.
The nurse is assessing a pregnant patient who is 30 weeks gestation and reports severe lower back pain. What is the most appropriate intervention for the nurse to recommend?
- A. Instruct the patient to lie flat on her back to relieve pain.
- B. Encourage the patient to perform gentle stretching exercises and maintain good posture.
- C. Encourage the patient to rest in bed and avoid any physical activity.
- D. Recommend taking over-the-counter pain medication to alleviate discomfort.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to perform gentle stretching exercises and maintain good posture. This option promotes active management of lower back pain in pregnancy by improving muscle strength and flexibility, reducing strain on the back. Stretching exercises can help alleviate discomfort and improve posture, which are important for managing back pain during pregnancy. Option A is incorrect as lying flat on the back is contraindicated in pregnancy due to the risk of supine hypotensive syndrome. Option C is incorrect as complete bed rest is not recommended for back pain management. Option D is incorrect as over-the-counter pain medication should be used judiciously during pregnancy and is not the first-line intervention for managing back pain.