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A 35-year-old patient is admitted to the delivery room having contractions 6 minutes apart. Upon palpation of the abdomen, the nurse feels a hard round object in the uterine fundus and a soft object in the pelvis. What should be anticipated?
- A. Cesarean section
- B. Imminent delivery
- C. Normal progressive labor and delivery
- D. FHR to be heard below the umbilicus
Correct Answer: A
Rationale: The correct answer is A: Cesarean section. In this scenario, the presence of a hard round object in the uterine fundus and a soft object in the pelvis indicates a situation of breech presentation. Since the baby is presenting in a breech position, it is not safe for a vaginal delivery due to potential complications and risks involved. Therefore, a cesarean section should be anticipated to ensure a safe delivery for both the mother and the baby.
Summary of other choices:
B: Imminent delivery - Unlikely as the breech presentation may complicate the delivery process.
C: Normal progressive labor and delivery - Inconsistent with the breech presentation findings.
D: FHR to be heard below the umbilicus - FHR location does not impact the need for a cesarean section in breech presentation.
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What is the primary goal of fetal heart rate monitoring during the second stage of labor?
- A. to predict when to bear down during contractions
- B. to determine the strength of the uterine contractions
- C. to evaluate fetal well-being
- D. to monitor vital signs of the birthing person
Correct Answer: C
Rationale: The primary goal of fetal heart rate monitoring during the second stage of labor is to evaluate fetal well-being. This is crucial to ensure that the baby is tolerating labor and delivery well. Monitoring fetal heart rate helps identify any signs of distress or compromise in oxygen supply to the baby. It guides healthcare providers in making timely interventions if needed to prevent adverse outcomes. Choices A and B are incorrect because the primary goal is not about timing contractions or assessing uterine contractions strength. Choice D is incorrect as the focus is not on monitoring the vital signs of the birthing person but on assessing the well-being of the fetus.
The nurse is caring for a pregnant patient who is 38 weeks gestation and reports feeling pelvic pressure and mild cramping. What should the nurse do first?
- A. Monitor the fetal heart rate and check for signs of labor.
- B. Instruct the patient to rest and monitor the symptoms.
- C. Assess the patient's blood pressure and urine for protein.
- D. Perform a pelvic exam to assess for cervical dilation.
Correct Answer: A
Rationale: The correct answer is A because monitoring the fetal heart rate and checking for signs of labor are essential in assessing the well-being of the fetus and determining if the patient is in active labor. This step helps the nurse identify any potential complications and take appropriate actions promptly.
Choice B is incorrect because simply instructing the patient to rest may not address the underlying cause of pelvic pressure and cramping.
Choice C is incorrect as assessing blood pressure and urine for protein is not the priority in this situation.
Choice D is incorrect because performing a pelvic exam should be done after monitoring fetal well-being and ruling out active labor.
A nurse is caring for a pregnant patient who is at 26 weeks gestation and reports a sudden decrease in fetal movement. Which action should the nurse take first?
- A. Encourage the patient to drink a sugary beverage and count fetal movements.
- B. Monitor the patient's blood pressure and assess for any signs of hypertension.
- C. Perform a nonstress test to assess fetal well-being.
- D. Call the healthcare provider immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a sugary beverage and count fetal movements. This action is appropriate as decreased fetal movement can indicate fetal distress, and the sugary beverage can stimulate the baby to move. If the baby responds with increased movements, it indicates a reassuring fetal status. If there is no improvement, further evaluation can be pursued.
Incorrect choices:
B: Monitoring blood pressure is not the priority in this situation as the main concern is fetal movement.
C: Performing a nonstress test is not the first action to take as it requires time and resources, which may delay immediate intervention.
D: While eventually contacting the healthcare provider is important, the immediate action should be to assess fetal well-being by encouraging fetal movements.
A pregnant patient at 24 weeks gestation reports feeling fatigued and lightheaded. What is the nurse's first priority action?
- A. Encourage the patient to rest and drink fluids.
- B. Monitor the patient's blood pressure and assess for signs of anemia.
- C. Administer iron supplements to alleviate fatigue.
- D. Instruct the patient to avoid any physical activity until symptoms subside.
Correct Answer: B
Rationale: The correct answer is B. Monitoring the patient's blood pressure and assessing for signs of anemia is the first priority because fatigue and lightheadedness in pregnancy can be symptoms of anemia or other serious conditions. Anemia can lead to complications for both the mother and the baby. Encouraging rest and fluids (choice A) is important but should come after ruling out any potential serious conditions. Administering iron supplements (choice C) without proper assessment can be harmful if anemia is not the cause. Instructing the patient to avoid physical activity (choice D) without proper evaluation can delay necessary interventions.
The nurse is educating a pregnant patient on the importance of maintaining a balanced diet during pregnancy. Which of the following statements by the patient indicates effective teaching?
- A. I should avoid all carbohydrates to prevent gestational diabetes.
- B. I need to eat extra food for my baby to ensure proper growth.
- C. I will eat a variety of nutrient-dense foods and avoid processed foods.
- D. I can focus on eating as much protein as possible to support my baby's development.
Correct Answer: C
Rationale: Rationale: Choice C is correct because it emphasizes the importance of eating a variety of nutrient-dense foods and avoiding processed foods. This approach ensures the pregnant patient receives essential nutrients for her health and the baby's development. Variety helps cover all necessary nutrients, while avoiding processed foods reduces the intake of unhealthy additives. This balanced diet promotes optimal health outcomes for both the mother and the baby.
Summary of Incorrect Choices:
A: Avoiding all carbohydrates is not recommended as they are a vital energy source and cutting them out completely can lead to nutritional deficiencies.
B: Eating extra food indiscriminately can result in excessive weight gain and complications. The focus should be on nutrient-dense foods, not just quantity.
D: Focusing solely on protein neglects other important nutrients needed during pregnancy. A well-rounded diet is essential for overall health.