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A nurse is caring for a laboring person in the first stage of labor. What is the priority assessment during this stage?
- A. assess fetal heart rate
- B. monitor contractions
- C. administer oxytocin
- D. check for cervical dilation
Correct Answer: A
Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring fetal well-being is the priority to ensure the baby's safety. Assessing the fetal heart rate helps determine if the baby is tolerating labor well. Monitoring contractions (B) is important but assessing the fetal heart rate takes precedence. Administering oxytocin (C) should be done based on specific indications and not as a routine assessment during the first stage of labor. Checking for cervical dilation (D) is important but does not take priority over assessing fetal well-being.
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Which foods equal 1 ounce serving size from the grain group? Select all that apply.
- A. 1 bagel
- B. 1 slice of bread
- C. 1 cup cooked pasta
- D. 1 tortilla
Correct Answer: B
Rationale: 1 slice of bread and 1 tortilla each equal 1 ounce serving size. A bagel and 1 cup cooked pasta exceed this size.
A woman in labor begins to experience severe chest pain and difficulty breathing. What should the nurse suspect?
- A. Pulmonary embolism
- B. Pre-eclampsia
- C. Anxiety
- D. Placental abruption
Correct Answer: A
Rationale: The correct answer is A: Pulmonary embolism. In a woman in labor experiencing severe chest pain and difficulty breathing, a pulmonary embolism should be suspected. This condition occurs when a blood clot travels to the lungs, causing chest pain and respiratory distress. Other choices are incorrect: B) Pre-eclampsia is characterized by high blood pressure and protein in the urine, not chest pain. C) Anxiety does not typically present with severe chest pain and difficulty breathing. D) Placental abruption involves separation of the placenta from the uterus, leading to vaginal bleeding and abdominal pain, not chest pain.
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.
A nurse is educating a pregnant patient about warning signs to report during pregnancy. Which of the following statements indicates that the teaching has been effective?
- A. I should report any sudden increase in swelling, especially in my hands and face.
- B. I should wait until after my due date to report any concerns.
- C. I should only report changes in fetal movement after the third trimester.
- D. I don't need to report headaches or blurry vision unless they are severe.
Correct Answer: A
Rationale: The correct answer is A because sudden increase in swelling, especially in hands and face, can indicate preeclampsia, a serious condition during pregnancy. Swelling in these areas can be a sign of fluid retention and increased blood pressure. Prompt reporting and intervention are crucial to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because:
B: Waiting until after the due date to report concerns can lead to missed opportunities for early intervention and can be dangerous for both the mother and the baby.
C: Changes in fetal movement should be reported immediately, not just after the third trimester, as they can indicate fetal distress.
D: Headaches and blurry vision, even if not severe, can be symptoms of preeclampsia or other serious conditions that require immediate attention. Waiting for symptoms to worsen can be harmful.
A patient with a history of gestational diabetes is admitted to the labor and delivery unit. What is the most important factor to monitor during labor?
- A. Maternal blood pressure
- B. Fetal heart rate
- C. Blood glucose levels
- D. Maternal temperature
Correct Answer: C
Rationale: The correct answer is C: Blood glucose levels. During labor, it is crucial to monitor the blood glucose levels of a patient with a history of gestational diabetes to prevent complications such as hyperglycemia or hypoglycemia. Fluctuations in blood glucose levels can impact both the mother and the baby's health. Monitoring maternal blood pressure (A) is important but not the most critical factor in this scenario. Fetal heart rate (B) is essential but does not directly address the specific needs of a patient with a history of gestational diabetes. Maternal temperature (D) is also important but does not take precedence over monitoring blood glucose levels in this case.