Nokea
A nurse is assisting a laboring person who is in the first stage of labor. What is the most appropriate intervention to promote relaxation and comfort?
- A. encourage ambulation
- B. administer pain medication
- C. provide distraction and breathing techniques
- D. offer relaxation techniques
Correct Answer: A
Rationale: The correct answer is A: encourage ambulation. Walking during the first stage of labor can help facilitate the descent of the fetus, promote optimal positioning, and enhance comfort by utilizing gravity to aid in the progression of labor. Ambulation also encourages blood circulation and may provide a distraction from discomfort. Administering pain medication (B) is not the initial intervention in promoting relaxation and comfort during early labor. Providing distraction and breathing techniques (C) may be beneficial, but ambulation is more effective in promoting relaxation. Offering relaxation techniques (D) is helpful, but encouraging movement through ambulation is a more active approach in easing discomfort and promoting relaxation during the first stage of labor.
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A nurse is preparing a postpartum person for discharge. What is the most important aspect of discharge teaching for a person who has had a cesarean section?
- A. ensure proper incision care
- B. teach about signs of infection
- C. provide skin-to-skin contact
- D. assess for bleeding
Correct Answer: B
Rationale: The correct answer is B: teach about signs of infection. This is the most important aspect of discharge teaching for a person who has had a cesarean section because infection is a common complication post-surgery. By educating the person on signs of infection such as fever, increased pain, redness, or discharge from the incision site, they can promptly seek medical attention if needed. Ensuring proper incision care (choice A) is important but preventing infection through early detection is crucial. Providing skin-to-skin contact (choice C) is beneficial for bonding but not directly related to post-cesarean care. Assessing for bleeding (choice D) is important but typically done in a healthcare setting post-surgery.
A pregnant patient is at 32 weeks gestation and reports feeling fatigued and weak. What is the nurse's priority intervention?
- A. Assess the patient's hemoglobin levels to check for anemia.
- B. Encourage the patient to increase physical activity and exercise.
- C. Instruct the patient to rest and avoid any strenuous activity.
- D. Recommend a high-calorie diet to improve energy levels.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's hemoglobin levels to check for anemia.
1. During pregnancy, anemia is common due to increased blood volume and demands. Fatigue and weakness are common symptoms.
2. Anemia can lead to complications for both the mother and baby if left untreated.
3. Assessing hemoglobin levels will help determine if anemia is present and guide appropriate interventions.
4. Prompt treatment of anemia can improve symptoms and prevent adverse outcomes.
Summary:
B: Increasing physical activity may exacerbate fatigue if anemia is present.
C: Resting is important, but addressing the underlying cause of fatigue is crucial.
D: A high-calorie diet may not address the root cause of fatigue and could potentially worsen anemia if not properly managed.
A pregnant patient with a history of anemia is asking the nurse about managing iron deficiency. Which of the following statements by the nurse would be most appropriate?
- A. Iron supplements should be taken with milk for better absorption.
- B. Iron supplements should be taken with a source of vitamin C to enhance absorption.
- C. Iron supplements should be avoided during the second trimester.
- D. Iron supplements should be taken at night before bed.
Correct Answer: B
Rationale: The correct answer is B: Iron supplements should be taken with a source of vitamin C to enhance absorption. Iron absorption is increased in the presence of vitamin C. Vitamin C helps convert iron into a more absorbable form. This is crucial for managing iron deficiency anemia in pregnant patients.
Incorrect choices:
A: Iron supplements should not be taken with milk as calcium in milk can hinder iron absorption.
C: Iron supplements are safe to take throughout pregnancy, and avoiding them during the second trimester is not recommended.
D: There is no specific recommendation to take iron supplements at night before bed; it can be taken at any time of the day.
A nurse is caring for a postpartum person who is at risk for thrombophlebitis. What is the most important intervention to reduce this risk?
- A. administer anticoagulants
- B. apply compression stockings
- C. use a footstool
- D. monitor for signs of DVT
Correct Answer: A
Rationale: The correct answer is A: administer anticoagulants. Anticoagulants help prevent blood clots, reducing the risk of thrombophlebitis. Administering anticoagulants is the most effective intervention for someone at risk. Applying compression stockings (B) can help with circulation but may not be sufficient for someone at high risk. Using a footstool (C) can promote circulation but is not as direct as anticoagulants. Monitoring for signs of DVT (D) is important but not as proactive as administering anticoagulants for prevention.
Can the baby's sex be determined at 8 weeks' gestation?
- A. Doctor knows the sex
- B. Organs are formed but too small
- C. Technician sees a penis
- D. It will take another month
Correct Answer: D
Rationale: At 8 weeks, organs are developing but too small to determine sex; this usually occurs around 18–20 weeks.