Nokea
A nurse is assisting with a vaginal delivery. What is the most important intervention when the head begins to crown?
- A. apply gentle downward pressure
- B. apply upward pressure
- C. assist with positioning
- D. assist with perineal massage
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps prevent rapid delivery to avoid perineal tearing and allows controlled stretching of the perineum. Applying upward pressure (B) can increase the risk of tearing. Positioning (C) is important but not the most critical at this stage. Perineal massage (D) is typically done before crowning, not during.
You may also like to solve these questions
A nurse is assisting with a vaginal delivery. What is the most important intervention when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. perform perineal massage
- C. assist with perineal care
- D. apply a warm compress
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps to control the speed of delivery, prevent rapid tearing of the perineum, and reduce the risk of maternal and fetal complications. Applying pressure can also help guide the baby's head to prevent sudden expulsion, allowing for a controlled delivery. Performing perineal massage (B) and assisting with perineal care (C) are important but not the most critical interventions at this stage. Applying a warm compress (D) may provide comfort but does not address the immediate need for controlled delivery.
A nurse is caring for a birthing person who is experiencing a late deceleration in fetal heart rate. What is the most appropriate action for the nurse to take?
- A. turn the laboring person to the left side
- B. increase maternal oxygen supply
- C. prepare for an emergency cesarean section
- D. administer terbutaline
Correct Answer: A
Rationale: The correct action for a nurse when a birthing person experiences late deceleration in fetal heart rate is to turn the laboring person to the left side. This helps improve placental perfusion by reducing pressure on the vena cava, enhancing blood flow to the uterus, and thus improving oxygenation to the fetus. This action can help alleviate the late deceleration and prevent fetal distress. Increasing maternal oxygen supply (choice B) is important but not the first-line intervention for late decelerations. Emergency cesarean section (choice C) is not typically indicated for late decelerations unless other interventions fail. Administering terbutaline (choice D) is not appropriate for late decelerations as it is a tocolytic used to inhibit uterine contractions and prevent preterm labor.
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.
The nurse is caring for a pregnant patient at 24 weeks gestation who reports increased vaginal discharge. What should the nurse do first?
- A. Assess the characteristics of the discharge, including color and odor.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Instruct the patient to wear a sanitary pad and track the amount of discharge.
- D. Perform a pelvic exam to check for signs of infection or complications.
Correct Answer: A
Rationale: Rationale:
Step 1: Assess characteristics of discharge - determining color and odor helps identify if it's normal or concerning.
Step 2: Based on assessment, decide next steps - presence of abnormal color or odor may indicate infection or other issues.
Step 3: Implement appropriate interventions - further evaluation or treatment as needed.
Summary:
- B: Resting and monitoring alone may not address the underlying cause of increased discharge.
- C: While tracking amount is important, it doesn't provide immediate information on potential infection.
- D: Performing a pelvic exam should come after initial assessment of discharge characteristics to guide further actions.
A nurse midwife has advised a 39-week gestation gravid to take evening primrose oil 2,500 mg daily as a complementary therapy. This suggestion was made because evening primrose has been shown to perform which of the following actions?
- A. Relieve back strain.
- B. Improve development of colostrum.
- C. Ripen the cervix.
- D. Reduce the incidence of hemorrhoids.
Correct Answer: C
Rationale: Evening primrose oil is believed to help ripen the cervix in preparation for labor. It is not typically used to relieve back strain, improve colostrum development, or reduce hemorrhoids.