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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.
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A pregnant patient is 32 weeks gestation and reports having trouble sleeping. Which of the following interventions should the nurse recommend?
- A. Take a warm bath and avoid using any pillows.
- B. Sleep on your back to relieve pressure on the uterus.
- C. Sleep with several pillows to elevate the upper body.
- D. Take sedatives to ensure a good night's sleep.
Correct Answer: C
Rationale: The correct answer is C: Sleep with several pillows to elevate the upper body. Elevating the upper body with pillows can help relieve discomfort from heartburn, shortness of breath, and back pain commonly experienced during pregnancy. This position promotes better circulation and reduces pressure on the uterus.
Incorrect choices:
A: Taking a warm bath may help relax but does not address the underlying sleep issues.
B: Sleeping on the back can compress major blood vessels, leading to decreased blood flow to the fetus.
D: Taking sedatives is not recommended during pregnancy due to potential risks to the fetus.
A nurse is providing prenatal education to a patient who is 22 weeks gestation. Which of the following topics should be emphasized at this stage of pregnancy?
- A. Signs and symptoms of preterm labor
- B. Signs of gestational diabetes
- C. Breastfeeding education
- D. Postpartum care
Correct Answer: A
Rationale: The correct answer is A: Signs and symptoms of preterm labor. At 22 weeks gestation, it is crucial to educate the patient about potential signs of preterm labor to help prevent premature birth and ensure the well-being of the baby. Symptoms such as regular contractions, abdominal cramping, backache, and vaginal bleeding should be discussed. This topic is time-sensitive and requires immediate action if observed.
Summary of other choices:
B: Signs of gestational diabetes - While important, monitoring for gestational diabetes typically occurs later in pregnancy, usually around 24-28 weeks.
C: Breastfeeding education - Important, but not as time-sensitive as preterm labor education.
D: Postpartum care - Relevant but more appropriate for later stages of pregnancy or after birth, not specifically at 22 weeks gestation.
The following four changes occur during pregnancy. Which of them usually increases the father’s interest and involvement in the pregnancy?
- A. Learning the results of the pregnancy test.
- B. Attending childbirth education classes.
- C. Hearing the fetal heartbeat.
- D. Meeting the obstetrician or midwife.
Correct Answer: C
Rationale: Hearing the fetal heartbeat is a significant moment that often increases the father’s interest and involvement in the pregnancy. The other options may also increase involvement but are less impactful.
A patient in labor is having difficulty pushing during the second stage of labor. Which of the following interventions would be most helpful?
- A. Increase the epidural dose
- B. Encourage the patient to bear down with each contraction
- C. Perform a cesarean section
- D. Place the patient in a lithotomy position
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to bear down with each contraction. This is the most helpful intervention as it helps the patient effectively push during the second stage of labor, facilitating the descent of the baby through the birth canal. Increasing the epidural dose (choice A) can further impair the patient's ability to push. Performing a cesarean section (choice C) is not necessary unless there are other complications. Placing the patient in a lithotomy position (choice D) is a common position for delivery but does not address the issue of difficulty pushing.
A nurse is preparing to administer a medication to a birthing person with a history of hypertension. What is the nurse's priority assessment before administering this medication?
- A. Blood pressure and pulse rate
- B. Respiratory rate and oxygen saturation
- C. Temperature and urine output
- D. Oxygen saturation and urine output
Correct Answer: A
Rationale: The correct answer is A: Blood pressure and pulse rate. For a birthing person with a history of hypertension, it is crucial to assess their blood pressure and pulse rate before administering medication to ensure the medication does not exacerbate their hypertension. Monitoring these vital signs helps in determining the appropriateness and safety of the medication.
Summary:
- Choice B is incorrect because respiratory rate and oxygen saturation are not the priority assessments for a person with a history of hypertension.
- Choice C is incorrect as temperature and urine output are not directly related to assessing the risk of exacerbating hypertension.
- Choice D is incorrect as oxygen saturation and urine output are not the primary indicators of medication safety for someone with hypertension.