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A nurse is assisting with a vaginal birth and notices a prolapsed umbilical cord. What is the immediate nursing action?
- A. administer oxygen via mask
- B. place the person in the knee-chest position
- C. reposition the laboring person
- D. prepare for an emergency delivery
Correct Answer: A
Rationale: The correct immediate nursing action for a prolapsed umbilical cord is to administer oxygen via mask (Choice A). This is crucial to ensure adequate oxygenation to the fetus as the prolapsed cord can compress and compromise blood flow. Administering oxygen helps maintain fetal oxygenation until emergency measures can be taken. Placing the person in the knee-chest position (Choice B) is contraindicated as it can further compress the cord. Repositioning the laboring person (Choice C) may not effectively relieve pressure on the cord. While preparing for an emergency delivery (Choice D) is important, administering oxygen is the priority to ensure fetal well-being.
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Which of the following is an appropriate intervention for a birthing person experiencing preterm labor?
- A. administer tocolytics
- B. administer antibiotics
- C. provide hydration and rest
- D. offer pain relief
Correct Answer: A
Rationale: The correct answer is A: administer tocolytics. Tocolytics help inhibit uterine contractions and can delay preterm labor, giving time for other interventions. Administering antibiotics (B) would not directly address preterm labor. Providing hydration and rest (C) may be helpful but not a direct intervention. Offering pain relief (D) does not address the underlying cause of preterm labor. Administering tocolytics is crucial in managing preterm labor to prevent premature birth and associated complications.
An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.
- A. Amenorrhea.
- B. Breast tenderness.
- C. Quickening.
- D. Frequent urination.
Correct Answer: A
Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.
A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
- A. Instruct the patient to avoid standing for long periods.
- B. Encourage the patient to increase sodium intake.
- C. Recommend that the patient take frequent naps during the day.
- D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.
A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.
The nurse is educating a pregnant patient about the importance of prenatal vitamins. Which statement by the patient indicates effective teaching?
- A. I will take prenatal vitamins only during the first trimester.
- B. I will take prenatal vitamins throughout the pregnancy to support my baby's growth.
- C. Prenatal vitamins are only necessary if I have a history of birth defects in my family.
- D. I should stop taking prenatal vitamins after the baby is born.
Correct Answer: B
Rationale: The correct answer is B: "I will take prenatal vitamins throughout the pregnancy to support my baby's growth." This statement indicates effective teaching because prenatal vitamins are essential for the entire duration of pregnancy to support the developing baby's growth and development. Prenatal vitamins contain key nutrients like folic acid, iron, and calcium that are crucial for the health of both the mother and the baby throughout the pregnancy. Taking prenatal vitamins only during the first trimester (option A) may not provide adequate support for the baby's growth during the entire pregnancy. Option C is incorrect because prenatal vitamins are recommended for all pregnant women, regardless of their family history of birth defects. Option D is incorrect because stopping prenatal vitamins after the baby is born does not align with the need to support the mother's postpartum health and potential breastfeeding needs.
A nurse is assessing a laboring person for signs of uterine rupture. What is the most common sign of uterine rupture?
- A. abdominal pain
- B. vaginal bleeding
- C. decreased fetal movement
- D. increased fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: decreased fetal movement. Uterine rupture can lead to decreased blood flow to the fetus, resulting in reduced fetal movement. This sign is crucial as it indicates fetal distress and the need for immediate medical intervention. Abdominal pain (A) can be present but is not specific to uterine rupture. Vaginal bleeding (B) is a sign of placental abruption, not uterine rupture. Increased fetal heart rate (D) can occur due to fetal distress, but decreased fetal movement is a more direct sign of uterine rupture.