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A nurse is caring for a laboring person who is experiencing irregular fetal heart rate patterns. What is the most appropriate intervention?
- A. increase oxygen flow
- B. increase fetal monitoring
- C. administer an analgesic
- D. increase fluid intake
Correct Answer: B
Rationale: The correct answer is B, to increase fetal monitoring. This is crucial to assess the fetal well-being and identify any potential distress or complications early on. Monitoring allows for timely interventions to be implemented to optimize outcomes. Increasing oxygen flow (A) may be necessary in some cases, but it is not the initial priority. Administering an analgesic (C) may help with pain management but does not address the fetal heart rate patterns. Increasing fluid intake (D) is important for hydration but is not directly related to managing fetal heart rate patterns.
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A pregnant patient is at 32 weeks gestation and reports swelling of the feet and legs. What is the most appropriate recommendation for the nurse to make?
- A. Limit fluid intake to reduce swelling.
- B. Elevate the legs and avoid prolonged standing.
- C. Apply compression stockings to improve circulation.
- D. Rest in bed with the feet elevated at all times.
Correct Answer: B
Rationale: The correct answer is B. Elevating the legs and avoiding prolonged standing is the most appropriate recommendation for a pregnant patient experiencing swelling at 32 weeks gestation. Elevating the legs helps to reduce swelling by aiding in venous return and reducing fluid accumulation in the lower extremities. Prolonged standing can worsen swelling due to increased pressure on the veins. Limiting fluid intake (choice A) may lead to dehydration and is not recommended during pregnancy. Applying compression stockings (choice C) may help improve circulation but may not address the underlying cause of swelling. Resting in bed with feet elevated at all times (choice D) is excessive and may not be practical for the patient.
The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix?
- A. They are destroyed by the acidic pH of the vagina.
- B. They survive up to 5 days and can cause pregnancy.
- C. They lose their motility in about 12 hours after intercourse.
- D. They are usually pushed out of the vagina by the muscular action of the vaginal wall.
Correct Answer: B
Rationale: Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.
The nurse is caring for a patient who is in labor with her first child. The patient's mother is present for support and notes that things have changed in the delivery room since she last gave birth in the early 1980s. Which current trend or intervention may the patient's mother find most different?
- A. Fetal monitoring throughout labor
- B. Postpartum stay of 10 days
- C. Expectant partner and family in operating room for cesarean birth
- D. Hospital support for breastfeeding
Correct Answer: D
Rationale: Step 1: The correct answer is D because hospital support for breastfeeding is a current trend that has significantly changed since the early 1980s. Back then, breastfeeding support in hospitals was minimal or nonexistent.
Step 2: Hospitals now provide extensive support for breastfeeding, including lactation consultants, education, and resources to help new mothers succeed in breastfeeding.
Step 3: This change in practice is a significant departure from the past and reflects the growing awareness of the importance of breastfeeding for both the mother and the baby's health.
Step 4: In contrast, choices A, B, and C are not as significant changes or trends compared to the evolution of hospital support for breastfeeding. Fetal monitoring, postpartum stay duration, and family presence during cesarean births have been around for a while and have seen some modifications, but they are not as dramatic as the shift in breastfeeding support.
A patient who has been in labor for several hours is now fully dilated and ready to push. What is the first action the nurse should take?
- A. Encourage the patient to push with each contraction
- B. Prepare the delivery room for delivery
- C. Assess the fetal heart rate
- D. Administer pain relief
Correct Answer: C
Rationale: The correct answer is C: Assess the fetal heart rate. This is important to ensure the baby's well-being during the pushing phase. By monitoring the fetal heart rate, the nurse can detect any signs of distress or complications, allowing for prompt intervention if needed. Encouraging the patient to push (A) is appropriate once the fetal well-being is confirmed. While preparing the delivery room (B) is important, it is not the immediate priority. Administering pain relief (D) can be considered after assessing the fetal heart rate and ensuring the baby's safety.
What item represents a serving of meat?
- A. Deck of cards
- B. Paperback book
- C. Clenched fist
- D. Large tomato
Correct Answer: A
Rationale: A serving of meat is approximately the size of a deck of cards, which equates to about 3 ounces.