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A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is because an increase in energy is often seen in pregnant women shortly before labor begins, known as the "nesting instinct." This burst of energy can indicate that the body is preparing for labor.
A: Decreased vaginal discharge is not a sign that precedes labor. In fact, an increase in vaginal discharge is more common as labor approaches.
C: Urinary retention is not a sign of labor onset. In late pregnancy, pressure on the bladder may cause frequent urination, but retention is not typical.
D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor onset. Weight gain can fluctuate throughout pregnancy and is not a reliable indicator of impending labor.
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Which of the following should be implemented in is experiencing increased oral mucus should provide management of hypovolemic shock due to postpar- parent education on which of the following? tum hemorrhage? Select all that apply.
- A. Correctly positioning the infant for feedings
- B. IV fluid replacement with 5% dextrose
- C. Initiating cardiopulmonary resuscitation
- D. Administration of oxygen with a nonrebreather
Correct Answer: A
Rationale: The correct answer is A: Correctly positioning the infant for feedings. This is the most appropriate intervention as it addresses the specific issue of increased oral mucus in an infant, which can be a sign of difficulty feeding and potential aspiration. Positioning the infant correctly can help facilitate safe and effective feeding, reducing the risk of complications.
Summary of why other choices are incorrect:
B: IV fluid replacement with 5% dextrose - This choice does not directly address the issue of increased oral mucus and hypovolemic shock due to postpartum hemorrhage.
C: Initiating cardiopulmonary resuscitation - This choice is not indicated for the given scenario and is more appropriate for a life-threatening emergency situation.
D: Administration of oxygen with a nonrebreather - While oxygen may be necessary in certain cases, it does not address the specific issue of increased oral mucus and hypovolemic shock due to postpartum hemorrhage.
What is the best nursing action for a newborn experiencing hypothermia?
- A. Place the newborn in skin-to-skin contact with the mother
- B. Provide a warm blanket and monitor temperature
- C. Administer IV fluids to stabilize temperature
- D. Monitor glucose levels for hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation.
Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.
The nurse is educating a pregnant client about foods high in iron. Which food should be recommended?
- A. Milk.
- B. Chicken.
- C. Spinach.
- D. Bananas.
Correct Answer: C
Rationale: The correct answer is C: Spinach.
1. Spinach is high in iron, which is important for pregnant women to prevent anemia.
2. Milk (A) does not contain a significant amount of iron.
3. Chicken (B) is a good source of protein but not as high in iron as spinach.
4. Bananas (D) are rich in potassium but not iron, making them a less suitable choice for iron supplementation during pregnancy.
A patient has just been admitted to labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The patient wants to have a mediation free birth. When discussing medication alternatives, the nurse should be sure the patient understands that:
- A. maternal pain and stress can have a more adverse effect on the fetus than a small amount of analgesia
- B. In order to respect her wishes no pain medication will be given
- C. the use of medication allows the patient to rest and be less fatigued
- D. pain relief will allow a more enjoyable birth experience
Correct Answer: A
Rationale: The correct answer is A because maternal pain and stress can lead to increased levels of stress hormones, which can negatively affect the fetus. By providing a small amount of analgesia, the patient can experience relief from pain and stress without compromising the well-being of the fetus.
Option B is incorrect because it disregards the potential benefits of providing some pain relief to the patient while still respecting her desire for a medication-free birth.
Option C is incorrect because while medication may provide some rest and alleviate fatigue, the primary concern in this scenario is the impact on the fetus rather than the patient's comfort.
Option D is incorrect because the main focus should be on ensuring the safety and well-being of both the mother and the fetus, rather than solely on the mother's enjoyment of the birth experience.
A client at 12 weeks' gestation reports nausea and vomiting. What is the best dietary advice?
- A. Eat three large meals a day.
- B. Drink fluids with meals.
- C. Consume small, frequent meals throughout the day.
- D. Avoid protein-rich foods.
Correct Answer: C
Rationale: The correct answer is C: Consume small, frequent meals throughout the day. This advice helps manage nausea and vomiting during pregnancy by preventing an empty stomach, which can worsen symptoms. Eating small, frequent meals helps stabilize blood sugar levels and provides a steady source of nutrients for the developing fetus. It also reduces the likelihood of triggering nausea by avoiding large meals. Drinking fluids with meals (choice B) may exacerbate symptoms by filling up the stomach too quickly. Eating three large meals a day (choice A) can lead to overeating and may worsen nausea. Avoiding protein-rich foods (choice D) is not recommended as protein is essential for fetal development and overall health during pregnancy.