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A nurse is caring for a laboring person who is in the first stage of labor. What is the most important assessment to perform during this stage?
- A. assess fetal heart rate
- B. monitor contractions
- C. check blood pressure
- D. assist with breathing exercises
Correct Answer: A
Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring the fetal heart rate is crucial as it indicates the well-being of the baby. Changes in fetal heart rate can signal distress and prompt intervention. Monitoring contractions is important but assessing fetal well-being takes precedence. Checking blood pressure is important but not the most critical in this stage. Assisting with breathing exercises can help manage pain, but assessing fetal heart rate is more crucial for ensuring the baby's safety.
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Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
- A. Biophysical profile
- B. Multiple-marker screening
- C. Lecithin-to-sphingomyelin ratio
- D. Blood type and crossmatch of maternal and fetal serum
Correct Answer: B
Rationale: Multiple-marker screening analyzes maternal serum for abnormal levels of AFP, hCG, inhibin A, and estriol to detect chromosomal defects.
A pregnant woman who is 20 weeks gestation asks about the risk of consuming caffeine during pregnancy. Which of the following responses is most appropriate?
- A. It is safe to consume up to 200 mg of caffeine per day during pregnancy.
- B. You should avoid caffeine completely during pregnancy.
- C. Moderate caffeine consumption is okay, but avoid drinking coffee in the afternoon.
- D. Caffeine has no impact on your pregnancy, so you can drink it as desired.
Correct Answer: A
Rationale: The correct answer is A because current guidelines suggest that consuming up to 200 mg of caffeine per day is considered safe during pregnancy. This amount is unlikely to harm the developing fetus. Excessive caffeine intake has been associated with an increased risk of miscarriage and low birth weight.
Option B is incorrect as complete avoidance of caffeine is not necessary, but rather moderation is key. Option C is partially correct in emphasizing moderation but the recommendation to avoid coffee in the afternoon is not supported by evidence. Option D is incorrect as caffeine does have an impact on pregnancy, and unrestricted consumption is not advisable.
The nurse is caring for a 16-year-old patient who is 32 weeks pregnant with her first child, who is male. The patient's mother has accompanied her to today's visit. During the nursing assessment, the patient mentions that she is no longer in a relationship with the baby's father but her mother plans to help her. However, the patient's mother asks whether this will have any impact on the child. Which should the nurse indicate the child is at increased risk of during his adolescence?
- A. Hypertension
- B. Diabetes
- C. Alcohol abuse
- D. Intraventricular bleeding
Correct Answer: C
Rationale: The correct answer is C: Alcohol abuse. During adolescence, children of parents who have substance abuse issues, like alcohol, are at an increased risk of developing similar problems. This is due to genetic predisposition, environmental factors, and learned behavior. Children tend to model the behavior of their parents, and if they are exposed to alcohol abuse at a young age, they are more likely to engage in alcohol abuse themselves as they grow older.
Incorrect choices:
A: Hypertension - This choice is not directly related to the situation described and is not typically a risk factor associated with parental alcohol abuse.
B: Diabetes - Similar to choice A, diabetes is not directly linked to parental alcohol abuse and is not a common risk factor during adolescence in this scenario.
D: Intraventricular bleeding - This is a medical condition that is not typically influenced by parental alcohol abuse and is not a common risk factor during adolescence.
The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?
- A. Fetal heart rate via Doppler.
- B. Positive pregnancy test.
- C. Positive Chadwick’s sign.
- D. Montgomery gland enlargements.
Correct Answer: A
Rationale: A fetal heart rate detected via Doppler is a positive sign of pregnancy. A positive pregnancy test, Chadwick’s sign, and Montgomery gland enlargements are probable signs but not definitive.
A postpartum person is breastfeeding her newborn. What is the most appropriate action if the person is experiencing nipple pain?
- A. apply lanolin cream
- B. administer pain relief
- C. monitor the baby's latch
- D. provide distraction techniques
Correct Answer: B
Rationale: The correct answer is B: administer pain relief. Nipple pain during breastfeeding can be caused by various factors such as improper latch, engorgement, or infection. Administering pain relief can help alleviate the discomfort temporarily while addressing the root cause. Applying lanolin cream (choice A) may help with moisturizing the nipples but won't address the underlying issue causing the pain. Monitoring the baby's latch (choice C) is important for long-term prevention but may not provide immediate relief. Providing distraction techniques (choice D) is not addressing the physical pain and may not be effective in resolving the issue. Administering pain relief is the most appropriate immediate action to help the postpartum person manage the discomfort while addressing the cause of the pain.