Nokea
A nurse is caring for a postpartum person during the fourth stage of labor. The nurse is assessing uterine involution to ensure that the uterus is returning to its prepregnancy size and position. Which finding is indicative of normal uterine involution during this stage?
- A. Uterus is palpable at the level of the umbilicus.
- B. Uterine fundus is firm, at the level of the umbilicus.
- C. Uterus is displaced to the right side of the abdomen.
- D. Uterus is above the level of the umbilicus.
Correct Answer: B
Rationale: The correct answer is B because during the fourth stage of labor, the uterine fundus should be firm and at the level of the umbilicus. This indicates proper involution as the uterus is contracting and reducing in size. Choice A is incorrect as the uterus should not be palpable at the level of the umbilicus during normal involution. Choice C is incorrect as the uterus should not be displaced to the right side of the abdomen. Choice D is incorrect as the uterus should not be above the level of the umbilicus, as this would suggest inadequate involution.
You may also like to solve these questions
The following four changes occur during pregnancy. Which of them usually increases the father’s interest and involvement in the pregnancy?
- A. Learning the results of the pregnancy test.
- B. Attending childbirth education classes.
- C. Hearing the fetal heartbeat.
- D. Meeting the obstetrician or midwife.
Correct Answer: C
Rationale: Hearing the fetal heartbeat is a significant moment that often increases the father’s interest and involvement in the pregnancy. The other options may also increase involvement but are less impactful.
A patient at 37 weeks gestation is admitted with ruptured membranes. What is the first priority action for the nurse?
- A. Assess for signs of infection
- B. Check for cord prolapse
- C. Perform a vaginal exam to assess cervical dilation
- D. Perform a vaginal examination to check for fetal descent
Correct Answer: B
Rationale: The correct answer is B: Check for cord prolapse. This is the first priority action because a prolapsed cord is a life-threatening emergency that requires immediate intervention to prevent fetal hypoxia and distress. The nurse should quickly assess for cord presentation by performing a vaginal exam and relieving pressure on the cord if present.
Incorrect choices:
A: Assess for signs of infection - While infection is a concern with ruptured membranes, it is not the immediate priority over checking for cord prolapse.
C: Perform a vaginal exam to assess cervical dilation - Assessing cervical dilation can wait until after ruling out cord prolapse.
D: Perform a vaginal examination to check for fetal descent - Fetal descent assessment is not urgent compared to checking for cord prolapse in this scenario.
A pregnant patient is at 28 weeks gestation and is diagnosed with gestational diabetes. What is the most important aspect of the patient's care plan?
- A. Maintaining a healthy weight gain during pregnancy.
- B. Monitoring blood glucose levels and maintaining a balanced diet.
- C. Increasing fluid intake to reduce the risk of dehydration.
- D. Administering insulin to control blood sugar levels.
Correct Answer: B
Rationale: The correct answer is B: Monitoring blood glucose levels and maintaining a balanced diet. This is crucial for managing gestational diabetes, as it helps control blood sugar levels to prevent complications for both the mother and baby. Regular monitoring ensures timely adjustments to treatment. A balanced diet helps regulate blood sugar levels and provides essential nutrients for the baby's growth.
Choice A is important but not as critical as monitoring blood glucose levels, as weight gain should be monitored but is not the primary focus in gestational diabetes. Choice C is not directly related to managing gestational diabetes. Choice D may be necessary in some cases, but it is not the most important aspect of care compared to monitoring blood glucose levels and diet.
A nurse is providing prenatal education to a patient who is 22 weeks gestation. Which of the following topics should be emphasized at this stage of pregnancy?
- A. Signs and symptoms of preterm labor
- B. Signs of gestational diabetes
- C. Breastfeeding education
- D. Postpartum care
Correct Answer: A
Rationale: The correct answer is A: Signs and symptoms of preterm labor. At 22 weeks gestation, it is crucial to educate the patient about potential signs of preterm labor to help prevent premature birth and ensure the well-being of the baby. Symptoms such as regular contractions, abdominal cramping, backache, and vaginal bleeding should be discussed. This topic is time-sensitive and requires immediate action if observed.
Summary of other choices:
B: Signs of gestational diabetes - While important, monitoring for gestational diabetes typically occurs later in pregnancy, usually around 24-28 weeks.
C: Breastfeeding education - Important, but not as time-sensitive as preterm labor education.
D: Postpartum care - Relevant but more appropriate for later stages of pregnancy or after birth, not specifically at 22 weeks gestation.
A 34-week gestation woman calls the obstetric office stating, 'Since last night I have had three nosebleeds.'
- A. You should see the doctor to make sure you are not becoming severely anemic.
- B. Do you have a temperature?
- C. One of the hormones of pregnancy makes the nasal passages prone to bleeds.
- D. Do you use any inhaled drugs?
Correct Answer: C
Rationale: Pregnancy hormones increase blood supply to mucous membranes, making them more prone to bleeding. Nosebleeds are generally harmless unless associated with other symptoms.