Nokea
A nurse is assisting with a vaginal delivery. What is the most important nursing intervention when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. perform perineal massage
- C. administer pain relief
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps prevent rapid expulsion of the baby, reducing the risk of perineal tears and minimizing maternal discomfort. It also helps control the delivery process, ensuring a safe and controlled birth.
Incorrect Choices:
B: Perineal massage is not indicated at the crowning stage as it may interfere with the natural birthing process.
C: Administering pain relief should have been addressed earlier in labor and is not a priority at this stage.
D: Administering IV fluids is important for hydration but is not the most critical intervention when the fetal head is crowning.
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A gravid woman and her husband inform the nurse that they have just moved into a three-story home that was built in the 1930s. Which of the following is critical for the nurse to advise the woman to protect the unborn child?
- A. Stay out of any rooms that are being renovated.
- B. Drink water only from the hot water tap.
- C. Refrain from entering the basement.
- D. Climb the stairs only once per day.
Correct Answer: A
Rationale: Renovations in older homes may release lead dust or asbestos, which are harmful to the developing fetus. Drinking water from the hot tap, limiting stair climbing, or avoiding basements are less critical concerns compared to exposure to renovation hazards.
Why is pregnancy planning important for women of childbearing age?
- A. Much organogenesis occurs before the missed period
- B. Insurance preapproval is required
- C. No more than 3 pregnancies are recommended
- D. Pregnancies less than 2 years apart stress the cardiovascular system
Correct Answer: A
Rationale: Organogenesis occurs early in pregnancy, often before a missed period, making early intervention critical for fetal health.
A nurse is assessing the fetal heart rate of a laboring person. What is the most significant finding that would indicate fetal distress?
- A. variable decelerations
- B. late decelerations
- C. bradycardia
- D. accelerations
Correct Answer: C
Rationale: The correct answer is C, bradycardia. Bradycardia in the fetal heart rate is a significant finding indicating fetal distress because it signifies a heart rate below normal range, which can lead to inadequate oxygen supply to the fetus. Bradycardia can be a sign of fetal hypoxia, acidosis, or other serious conditions. Variable decelerations (choice A) are often caused by umbilical cord compression, late decelerations (choice B) are associated with uteroplacental insufficiency, and accelerations (choice D) are considered a reassuring sign of fetal well-being. Therefore, in the context of fetal distress, bradycardia is the most concerning finding.
The nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with a urinary tract infection (UTI). Which of the following interventions should the nurse prioritize?
- A. Administer antibiotics as prescribed.
- B. Encourage the patient to drink cranberry juice.
- C. Provide education about the signs of preterm labor.
- D. Schedule a follow-up ultrasound to assess fetal health.
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics as prescribed. The priority is to treat the UTI to prevent potential harm to the patient and fetus. Antibiotics are necessary to eliminate the infection and reduce the risk of complications. Encouraging cranberry juice (B) may be beneficial for prevention but is not sufficient to treat an existing UTI. Providing education about preterm labor signs (C) is important but addressing the infection is the immediate concern. Scheduling a follow-up ultrasound (D) may be necessary later but does not address the urgent need to treat the UTI.
A woman provides the nurse with the following obstetrical history: Delivered a son, now 7 years old, at 28 weeks’ gestation; delivered a daughter, now 5 years old, at 39 weeks’ gestation; had a miscarriage 3 years ago, and had a first-trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman’s gravidity and parity?
- A. G4 P2121.
- B. G4 P1212.
- C. G5 P1122.
- D. G5 P2211.
Correct Answer: D
Rationale: Gravidity includes all pregnancies (live births, miscarriages, abortions, and current pregnancy). Parity reflects live births. This woman has had 5 pregnancies (2 live births, 1 miscarriage, 1 abortion, and 1 current pregnancy), making her G5 P2211.