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A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head crowns?
- A. apply gentle downward pressure
- B. assist with shoulder delivery
- C. assist with perineal massage
- D. administer pain relief
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of perineal tearing and ensuring a controlled birth. Applying too much pressure can cause trauma to the mother and baby. Incorrect choices: B is premature, as shoulder delivery should only be done after the head and shoulders are delivered. C is not the most important action at crowning. D is not necessary at this specific stage of delivery.
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The nurse is caring for a pregnant patient who has a history of gestational hypertension. Which intervention is most important to reduce the risk of complications?
- A. Monitor blood pressure regularly during pregnancy.
- B. Encourage the patient to exercise vigorously.
- C. Instruct the patient to eat a high-sodium diet.
- D. Advise the patient to reduce her fluid intake to avoid edema.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood pressure regularly during pregnancy. Regular monitoring is crucial to detect any changes in blood pressure early and intervene promptly to prevent complications like preeclampsia.
Choice B is incorrect because vigorous exercise can increase blood pressure. Choice C is incorrect as a high-sodium diet can worsen hypertension. Choice D is incorrect as reducing fluid intake can lead to dehydration and potentially exacerbate hypertension. Regular blood pressure monitoring is key in managing gestational hypertension and ensuring the best outcomes for both the mother and the baby.
Which is an expected characteristic of amniotic fluid?
- A. Deep yellow color
- B. Clear, with small white particles
- C. Nitrazine test: acidic result
- D. Absence of ferning
Correct Answer: B
Rationale: The correct answer is B: Clear, with small white particles. Amniotic fluid is typically clear with small white particles, representing vernix caseosa. Vernix caseosa is a white, cheese-like substance that covers the skin of the fetus. It helps protect the skin and regulate body temperature. The presence of vernix particles in amniotic fluid is a normal and expected characteristic.
Incorrect choices:
A: Deep yellow color - Amniotic fluid is usually clear or slightly straw-colored. A deep yellow color may indicate the presence of meconium, which suggests fetal distress.
C: Nitrazine test: acidic result - Amniotic fluid is normally alkaline, not acidic. An acidic result may indicate infection.
D: Absence of ferning - Ferning is a characteristic pattern seen under a microscope in dried cervical mucus, not amniotic fluid. Absence of ferning in amniotic fluid is not a relevant characteristic.
A 38-week pregnant patient in active labor is experiencing frequent and painful contractions. What is the most appropriate action for the nurse?
- A. Administer narcotic analgesics for pain relief
- B. Provide emotional support and reassurance
- C. Assess the fetal heart rate and contraction patterns
- D. Prepare for delivery
Correct Answer: D
Rationale: The correct answer is D: Prepare for delivery. At 38 weeks of gestation and in active labor, the most appropriate action is to prepare for delivery as the patient is likely to be close to giving birth. This involves ensuring that all necessary equipment and supplies are ready, notifying the healthcare team, and positioning the patient for delivery. Administering narcotic analgesics (choice A) may not be ideal at this stage as the priority is the imminent delivery. While emotional support and reassurance (choice B) are important, they should be provided alongside preparing for delivery. Assessing the fetal heart rate and contraction patterns (choice C) is crucial but should be done concurrently with preparing for delivery to ensure the safety of both the mother and baby.
When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make?
- A. You are effectively meeting your daily fruit requirements.
- B. Fruit juices are excellent sources of folic acid.
- C. It would be even better if you were to consume more whole fruits and less fruit juice.
- D. Your fruit intake far exceeds the recommended daily fruit intake.
Correct Answer: C
Rationale: Whole fruits provide fiber and additional nutrients compared to fruit juices, which may contain added sugars. Encouraging increased consumption of whole fruits aligns with healthy dietary guidelines for pregnancy.
What is true about the morula stage of development?
- A. Fertilized egg has yet to implant
- B. Lung fields are completely formed
- C. Sex of fetus can be identified
- D. Eyelids begin to open and close
Correct Answer: A
Rationale: The morula stage occurs before implantation, representing an early phase of embryonic development.