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A nurse is assessing a 36-week pregnant patient who is complaining of sudden and severe headaches. What is the nurse's priority action?
- A. Encourage the patient to take a warm shower and rest.
- B. Assess the patient's blood pressure and check for signs of preeclampsia.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to drink more water to stay hydrated.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's blood pressure and check for signs of preeclampsia. Sudden and severe headaches in a pregnant patient could indicate preeclampsia, a serious condition characterized by high blood pressure. The nurse's priority is to assess for signs of preeclampsia to ensure the safety of both the mother and the baby. Encouraging rest or a warm shower, administering pain medication, or advising hydration do not address the potential underlying issue of preeclampsia and could delay necessary medical intervention.
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A nurse is caring for a postpartum person during the fourth stage of labor. The nurse is assessing uterine involution to ensure that the uterus is returning to its prepregnancy size and position. Which finding is indicative of normal uterine involution during this stage?
- A. Uterus is palpable at the level of the umbilicus.
- B. Uterine fundus is firm, at the level of the umbilicus.
- C. Uterus is displaced to the right side of the abdomen.
- D. Uterus is above the level of the umbilicus.
Correct Answer: B
Rationale: The correct answer is B because during the fourth stage of labor, the uterine fundus should be firm and at the level of the umbilicus. This indicates proper involution as the uterus is contracting and reducing in size. Choice A is incorrect as the uterus should not be palpable at the level of the umbilicus during normal involution. Choice C is incorrect as the uterus should not be displaced to the right side of the abdomen. Choice D is incorrect as the uterus should not be above the level of the umbilicus, as this would suggest inadequate involution.
The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not?
- A. 10%
- B. 25%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.
A nurse is assisting with a vaginal birth. What is the most appropriate nursing action when the head crowns during delivery?
- A. apply gentle pressure to the fetal head
- B. prepare for delivery of the placenta
- C. assist with shoulder delivery
- D. apply gentle pressure to the perineum
Correct Answer: A
Rationale: The correct answer is A: apply gentle pressure to the fetal head. This action helps prevent rapid delivery, reducing the risk of perineal tearing and promoting controlled delivery of the baby. Applying pressure also helps prevent the baby from being born too quickly, reducing the risk of umbilical cord compression and potential birth injuries.
Choices B, C, and D are incorrect because at the moment the head crowns, the priority is to assist with the controlled delivery of the baby's head. Delivering the placenta (B) and assisting with shoulder delivery (C) are steps that come after the baby's head is delivered. Applying pressure to the perineum (D) is not recommended as it may increase the risk of perineal tearing.
What organ does the ductus venosus shunt blood away from in fetal circulation?
- A. Liver
- B. Heart
- C. Lungs
- D. Kidneys
Correct Answer: A
Rationale: Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.
How should the nurse respond to a concern about alcohol exposure during conception?
- A. Inform the doctor
- B. Reassure it's unlikely the baby was affected
- C. Suggest abortion
- D. Recommend ultrasound
Correct Answer: B
Rationale: Occasional alcohol exposure around conception is unlikely to cause significant harm, though ongoing abstinence is advised.