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A nurse is assessing a postpartum person for signs of deep vein thrombosis (DVT). What is the most common sign of DVT in the postpartum period?
- A. Swelling and redness of the calf
- B. Pain in the lower leg
- C. Heat intolerance
- D. Cold intolerance
Correct Answer: A
Rationale: The correct answer is A: Swelling and redness of the calf. Postpartum women are at a higher risk for DVT due to hormonal changes and immobility. Swelling and redness in the calf indicate possible DVT as blood clots can cause inflammation and blockage in the veins. Pain in the lower leg (B) is a common symptom but not the most specific for DVT. Heat intolerance (C) and cold intolerance (D) are not typically associated with DVT and are unrelated symptoms in this context.
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When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: CVS is typically performed between 10 and 13 weeks of gestation to analyze fetal tissue for chromosomal, metabolic, or DNA abnormalities.
A nurse is assisting a laboring person with an epidural. What is the most important nursing intervention prior to the procedure?
- A. ensure proper positioning
- B. ensure informed consent
- C. monitor contractions
- D. assist with controlled breathing
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent. This is crucial before any medical procedure, including epidural administration. It ensures the laboring person understands the risks, benefits, and alternatives of the epidural. Proper positioning (choice A) is important during the procedure but not the most critical pre-procedure intervention. Monitoring contractions (choice C) and assisting with breathing (choice D) are important aspects of labor support but not directly related to obtaining informed consent for the epidural.
A biophysical profile is performed on a pregnant patient. The results show a nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of the hand indicating the presence of fetal tone, and adequate amniotic fluid index (AFI). What is the correct interpretation of this test result?
- A. A score of 10 would indicate that the results are equivocal.
- B. A score of 8 would indicate normal results.
- C. A score of 6 would indicate that birth should be considered as a possible treatment option.
- D. A score of 9 would indicate reassurance.
Correct Answer: B
Rationale: A biophysical profile score of 8-10 is considered normal, indicating fetal well-being.
A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
- A. ensure the birthing person is positioned correctly
- B. check for allergies to anesthesia
- C. administer a test dose of anesthesia
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. What sample will be collected for the initial screening process?
- A. Urine
- B. Blood
- C. Saliva
- D. Amniotic fluid
Correct Answer: B
Rationale: AFP screening is done using a blood sample, which is less invasive than an amniocentesis.