Nokea
A client asks the nurse, “Could you explain how the baby’s blood and my blood separate at delivery?” Which of the following responses is appropriate for the nurse to make?
- A. When the placenta is born, the circulatory systems separate.
- B. When the doctor clamps the cord, the blood stops mixing.
- C. The separation happens after the baby takes the first breath. The baby’s oxygen no longer has to come from you.
- D. The blood actually never mixes. Your blood supply and the baby’s blood supply are completely separate.
Correct Answer: D
Rationale: During pregnancy, the mother's and baby's blood supplies do not mix. The placenta acts as a barrier and facilitates the exchange of nutrients, gases, and waste products between the maternal and fetal bloodstreams without direct mixing. This ensures that each individual maintains their own circulatory system.
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A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most important intervention to prevent DVT?
- A. administer anticoagulants
- B. administer IV fluids
- C. perform leg exercises
- D. ensure early ambulation
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate hydration which prevents blood from becoming too thick and reduces the risk of clot formation. Adequate hydration also promotes blood circulation, decreasing the risk of DVT. Administering anticoagulants (choice A) is important in managing DVT but is not the most important preventive intervention. Performing leg exercises (choice C) and ensuring early ambulation (choice D) are also beneficial in preventing DVT, but maintaining hydration with IV fluids is the most crucial intervention as it directly addresses the primary factor contributing to DVT formation.
A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
The nurse is assessing a pregnant patient who is 30 weeks gestation and is concerned about the possibility of gestational diabetes. Which of the following symptoms should the nurse educate the patient to report?
- A. Increased thirst and frequent urination
- B. Sudden weight loss and increased energy
- C. Extreme fatigue and headaches
- D. Decreased fetal movement and nausea
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and frequent urination. This is because these symptoms are indicative of hyperglycemia, which is common in gestational diabetes. Increased thirst occurs due to the body trying to flush out excess sugar through urine, leading to frequent urination. This should be reported to the healthcare provider for further evaluation and management.
Other choices are incorrect:
B: Sudden weight loss and increased energy are not typical symptoms of gestational diabetes. Weight loss can occur in uncontrolled diabetes, but it is not a common symptom in gestational diabetes.
C: Extreme fatigue and headaches can be non-specific symptoms and are not necessarily related to gestational diabetes.
D: Decreased fetal movement and nausea are more commonly associated with other complications in pregnancy, such as placental insufficiency or preeclampsia, rather than gestational diabetes.
The midwife has just palpated the fundal height at the location noted on the picture below. It is likely that the client is how many weeks pregnant?
- A. 12
- B. 20
- C. 28
- D. 36
Correct Answer: B
Rationale: At 20 weeks, the fundal height is typically at the level of the umbilicus, which is consistent with the description provided.
A pregnant patient is at 30 weeks gestation and is experiencing difficulty breathing, especially when lying flat. What is the nurse's priority action?
- A. Encourage the patient to rest in an upright position.
- B. Administer oxygen and prepare the patient for delivery.
- C. Monitor the fetal heart rate for signs of distress.
- D. Instruct the patient to take deep breaths and stay in bed.
Correct Answer: A
Rationale: The correct answer is A - Encourage the patient to rest in an upright position. This is the priority action because the patient is likely experiencing supine hypotensive syndrome due to pressure on the vena cava when lying flat. This can compromise blood flow to the fetus. By having the patient rest in an upright position, the pressure on the vena cava is reduced, improving blood flow and oxygenation for both the patient and the fetus. Administering oxygen and preparing for delivery (option B) is not the immediate priority. Monitoring fetal heart rate (option C) is important but not the initial action. Instructing the patient to take deep breaths and stay in bed (option D) does not address the underlying issue of supine hypotensive syndrome.