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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.
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A 36-week pregnant woman presents to the labor and delivery unit in preterm labor. What is the priority intervention?
- A. Administer corticosteroids to promote fetal lung maturity
- B. Administer magnesium sulfate to stop labor
- C. Perform an emergency cesarean section
- D. Perform a nonstress test (NST)
Correct Answer: A
Rationale: The correct answer is A: Administer corticosteroids to promote fetal lung maturity. This is the priority intervention in preterm labor as it helps accelerate fetal lung development, reducing the risk of respiratory distress syndrome. Administering magnesium sulfate (B) is used for neuroprotection in preterm labor but is not the priority in this case. Emergency cesarean section (C) is not indicated unless there is a life-threatening situation. Performing a nonstress test (D) is important for fetal monitoring but is not the priority intervention in this scenario.
The nurse is caring for a pregnant patient who is concerned about preterm labor. Which of the following symptoms should the nurse instruct the patient to report immediately?
- A. Mild back pain and cramping
- B. Feeling of pelvic pressure
- C. Leaking of clear fluid from the vagina
- D. Increased fatigue during the day
Correct Answer: C
Rationale: The correct answer is C: Leaking of clear fluid from the vagina. This symptom could indicate premature rupture of membranes, which is a serious concern in preterm labor. Prompt reporting is crucial to prevent complications. A: Mild back pain and cramping are common in pregnancy and may not necessarily indicate preterm labor. B: Feeling of pelvic pressure can be normal in the third trimester. D: Increased fatigue is common in pregnancy and not a direct sign of preterm labor.
The nurse is caring for a pregnant patient at 34 weeks gestation who is experiencing leg cramps. What is the most appropriate recommendation for the nurse to make?
- A. Increase calcium and vitamin D intake to prevent cramps.
- B. Encourage the patient to perform leg stretches and elevate the legs.
- C. Administer pain medications and apply ice to the affected areas.
- D. Recommend frequent walking to strengthen leg muscles.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to perform leg stretches and elevate the legs. Leg cramps are common in pregnancy due to increased pressure on nerves and blood vessels. Leg stretches help relieve muscle tension, and elevating the legs promotes circulation. Increasing calcium and vitamin D may be helpful but not the primary intervention. Administering pain medications and applying ice may provide temporary relief but do not address the underlying cause. Frequent walking can help strengthen leg muscles but may exacerbate cramps if done excessively.
A nurse is monitoring a laboring person's vital signs during the first stage of labor. Which vital sign change is most likely to indicate the need for further evaluation?
- A. decrease in heart rate
- B. increase in blood pressure
- C. increase in pulse rate
- D. no change in vital signs
Correct Answer: B
Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby.
A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions.
C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high.
D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.
A nurse is caring for a pregnant patient who is experiencing nausea and vomiting. Which of the following should be included in the teaching plan?
- A. Eat small, frequent meals and avoid spicy or fatty foods.
- B. Drink large amounts of water to flush out toxins.
- C. Lie flat on your back to help settle your stomach.
- D. Avoid eating any food until the nausea resolves completely.
Correct Answer: A
Rationale: The correct answer is A: Eat small, frequent meals and avoid spicy or fatty foods. This is because small, frequent meals can help manage nausea by preventing the stomach from becoming too full, while avoiding spicy or fatty foods can reduce irritation and ease digestion. Option B is incorrect as excessive water intake can worsen nausea. Option C is wrong as lying flat on the back can exacerbate nausea and is not recommended during pregnancy. Option D is incorrect because skipping meals can lead to low blood sugar levels, worsening nausea. Overall, choice A aligns with evidence-based strategies for managing nausea and vomiting in pregnancy.