Nokea
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. administer pain relief
- C. administer analgesics
- D. perform perineal massage
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent the baby from being born too quickly, reducing the risk of tearing for the mother. It also ensures a controlled delivery, decreasing the likelihood of complications such as shoulder dystocia. Administering pain relief (B) or analgesics (C) may be necessary but not the most crucial at this moment. Performing perineal massage (D) is beneficial for reducing the risk of tearing but is not as important as guiding the baby's head during crowning.
You may also like to solve these questions
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.
A pregnant patient at 28 weeks gestation reports dizziness and faintness when standing. What is the nurse's most appropriate recommendation?
- A. Rise quickly from a seated position to avoid dizziness.
- B. Instruct the patient to increase fluid intake and stand slowly.
- C. Encourage the patient to rest in bed to prevent fainting.
- D. Advise the patient to avoid standing for long periods.
Correct Answer: B
Rationale: The correct answer is B: Instruct the patient to increase fluid intake and stand slowly. This recommendation is appropriate because the patient is likely experiencing orthostatic hypotension due to the expanding uterus compressing blood vessels, leading to decreased blood flow to the brain when standing. Increasing fluid intake helps maintain blood volume, while standing slowly helps prevent sudden drops in blood pressure.
A: Rising quickly can worsen dizziness by further decreasing blood flow to the brain.
C: Resting in bed may not address the underlying issue of orthostatic hypotension and may lead to deconditioning.
D: Avoiding standing for long periods may be impractical and may not address the need to maintain adequate blood volume and prevent sudden drops in blood pressure.
A nurse is assisting with a vaginal delivery. What is the most important action when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. perform perineal massage
- C. perform a vaginal exam
- D. assist with breathing exercises
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of tearing and allowing the perineum to stretch gradually. It also helps control the delivery, ensuring a safe and controlled birth process. Performing perineal massage (B) is beneficial during the pushing stage but is not the most important action when the head crowns. Performing a vaginal exam (C) is unnecessary and may increase the risk of infection. Assisting with breathing exercises (D) is important during labor but not specifically when the head crowns.
A nurse is caring for a postpartum person who is experiencing excessive bleeding. What should the nurse assess first?
- A. perform uterine massage
- B. perform a vaginal examination
- C. evaluate blood loss
- D. perform a uterine check
Correct Answer: A
Rationale: The correct answer is A: perform uterine massage. This is the priority because uterine massage helps to stimulate uterine contractions, which can help control bleeding in postpartum individuals. It is crucial to address the source of bleeding first. Performing a vaginal examination (choice B) may exacerbate bleeding. Evaluating blood loss (choice C) is important but not the initial step. Performing a uterine check (choice D) is vague and not as specific as uterine massage in addressing postpartum bleeding.
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.