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A 35-week pregnant woman presents with ruptured membranes. What is the priority intervention?
- A. Check for cord prolapse
- B. Monitor for fetal distress
- C. Administer antibiotics
- D. Perform a vaginal exam to assess cervical dilation
Correct Answer: A
Rationale: The correct answer is A: Check for cord prolapse. This is the priority intervention because with ruptured membranes, there is a risk of umbilical cord prolapse, which can lead to fetal compromise. Checking for cord prolapse allows for quick identification and immediate intervention to prevent potential harm to the baby.
Choice B is incorrect as monitoring for fetal distress is important but not the immediate priority when cord prolapse is a concern. Choice C, administering antibiotics, may be necessary but does not address the immediate risk of cord prolapse. Choice D, performing a vaginal exam, can increase the risk of infection and should be avoided until cord prolapse is ruled out.
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A nurse is caring for a pregnant patient who is at 40 weeks gestation and reports leaking clear fluid. What is the nurse's priority action?
- A. Check the fetal heart rate and assess the mother's vital signs.
- B. Encourage the patient to go home and rest until contractions begin.
- C. Instruct the patient to monitor fetal movement and call back if the fluid continues to leak.
- D. Call the healthcare provider immediately to report the rupture of membranes.
Correct Answer: D
Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.
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.
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
- A. Determine if a metabolic disorder exists.
- B. Identify the sex of the fetus.
- C. Identify abnormal fetal cells.
- D. Determine fetal lung maturity.
Correct Answer: D
Rationale: At 34 weeks, amniocentesis is primarily used to assess fetal lung maturity, which is critical if early delivery is being considered.
The nurse asks a woman about how the woman’s husband is dealing with the pregnancy.
- A. My husband is ready for the pregnancy to end so that we can have sex again.
- B. My husband has gained quite a bit of weight during this pregnancy.
- C. My husband seems more worried about our finances now than before the pregnancy.
- D. My husband plays his favorite music for my belly so the baby will learn to like it.
Correct Answer: A
Rationale: If the husband is overly focused on resuming sexual activity postpartum, it might indicate a lack of emotional support for the pregnant partner, warranting counseling.
A birthing person who delivered a newborn vaginally is receiving care in the labor and birth unit. The health-care provider diagnosed a retained placenta. What is the primary risk associated with a retained placenta?
- A. neonatal jaundice
- B. postpartum hemorrhage
- C. delayed bonding
- D. postpartum anemia
Correct Answer: B
Rationale: The primary risk associated with a retained placenta is postpartum hemorrhage. When the placenta does not deliver completely after childbirth, it can lead to excessive bleeding, risking the mother's health. This condition requires immediate medical attention to prevent severe complications. Neonatal jaundice, delayed bonding, and postpartum anemia are not directly linked to a retained placenta, making them incorrect choices. Neonatal jaundice is caused by elevated bilirubin levels, delayed bonding is related to emotional factors, and postpartum anemia is characterized by low red blood cell count, none of which are the primary risk associated with a retained placenta.