Nokea
A client asks the nurse what was meant when the physician told her she had a positive Chadwick’s sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time?
- A. It is a purplish stretch mark on your abdomen.
- B. It means that you are having heart palpitations.
- C. It is a bluish coloration of your cervix and vagina.
- D. It means the doctor heard abnormal sounds when you breathed in.
Correct Answer: C
Rationale: Chadwick’s sign is a bluish coloration of the cervix and vagina due to increased blood flow, which is a common early sign of pregnancy.
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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.
A nurse is caring for a pregnant woman who is at 40 weeks gestation and is experiencing a prolonged labor. Which of the following interventions is most appropriate to promote labor progression?
- A. Administer a sedative to help the patient rest.
- B. Encourage the patient to walk or change positions.
- C. Administer oxytocin to strengthen contractions.
- D. Perform a cesarean section immediately.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to walk or change positions. This intervention helps to promote gravity-assisted descent of the fetus, aiding in cervical dilation and labor progression. Walking and changing positions can also help alleviate pain and discomfort, facilitate optimal fetal positioning, and prevent maternal exhaustion. Administering a sedative (A) can potentially slow down labor progress. Administering oxytocin (C) may be indicated in certain situations, but it is not the most appropriate initial intervention for promoting labor progression in this case. Performing a cesarean section (D) is not warranted unless there are specific medical indications for it, as it is a major surgical procedure with potential risks.
Which food can a lactose-intolerant pregnant woman consume for calcium?
- A. Turnip greens
- B. Green beans
- C. Cantaloupe
- D. Nectarines
Correct Answer: A
Rationale: Turnip greens are rich in calcium, making them a suitable alternative for lactose-intolerant individuals.
A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
A nurse is assessing a laboring person for signs of fetal distress. What is the most common sign of fetal distress?
- A. increase oxygen flow
- B. tachycardia
- C. bradycardia
- D. irregular fetal heart rate
Correct Answer: B
Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.