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A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most appropriate nursing intervention?
- A. Encourage ambulation
- B. Apply compression stockings
- C. Administer low-molecular-weight heparin
- D. Monitor for signs of edema
Correct Answer: B
Rationale: The correct answer is B: Apply compression stockings. This intervention is appropriate for a postpartum person at risk for DVT as it helps promote circulation and prevent blood clots by applying pressure to the legs. Compression stockings are a safe and non-invasive method to reduce the risk of DVT. Encouraging ambulation (choice A) is important but may not be feasible immediately postpartum. Administering low-molecular-weight heparin (choice C) would require a prescription and may not be the first-line intervention. Monitoring for signs of edema (choice D) is important but does not directly address the prevention of DVT like compression stockings do.
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A nurse is assisting with a vaginal birth and notices a prolapsed umbilical cord. What is the immediate nursing action?
- A. administer oxygen via mask
- B. place the person in the knee-chest position
- C. reposition the laboring person
- D. prepare for an emergency delivery
Correct Answer: A
Rationale: The correct immediate nursing action for a prolapsed umbilical cord is to administer oxygen via mask (Choice A). This is crucial to ensure adequate oxygenation to the fetus as the prolapsed cord can compress and compromise blood flow. Administering oxygen helps maintain fetal oxygenation until emergency measures can be taken. Placing the person in the knee-chest position (Choice B) is contraindicated as it can further compress the cord. Repositioning the laboring person (Choice C) may not effectively relieve pressure on the cord. While preparing for an emergency delivery (Choice D) is important, administering oxygen is the priority to ensure fetal well-being.
The nurse is caring for a pregnant patient who is 38 weeks gestation and has a history of gestational hypertension. Which of the following symptoms would indicate the need for immediate medical attention?
- A. Mild swelling in the feet and ankles
- B. Headaches and blurred vision
- C. Occasional lower back pain
- D. Fatigue and slight nausea
Correct Answer: B
Rationale: The correct answer is B: Headaches and blurred vision. These symptoms can indicate a serious condition called preeclampsia, which can be life-threatening for both the mother and the baby. Headaches and blurred vision are signs of increased blood pressure and potential organ damage. Immediate medical attention is crucial to monitor and manage preeclampsia.
A: Mild swelling in the feet and ankles is common in pregnancy and not necessarily indicative of a serious issue.
C: Occasional lower back pain is also common in pregnancy and may not require immediate medical attention.
D: Fatigue and slight nausea are common pregnancy symptoms and do not typically indicate a need for immediate medical attention.
What is the most common complication of a cesarean birth?
- A. infection
- B. hemorrhage
- C. urinary retention
- D. scar tissue
Correct Answer: A
Rationale: The correct answer is A: infection. Infection is the most common complication of a cesarean birth due to the incision made during the procedure, which can introduce bacteria. Infections can lead to various complications if not treated promptly. Hemorrhage (B) can occur but is less common than infection. Urinary retention (C) and scar tissue (D) are potential complications of cesarean birth but are not as common as infection.
During the first stage of labor, what is the primary goal of nursing care in the early phase?
- A. Administer pain medication.
- B. Monitor fetal heart rate continuously.
- C. Promote relaxation and provide comfort measures.
- D. Prepare for imminent delivery.
Correct Answer: C
Rationale: The correct answer is C because during the early phase of labor, the primary goal of nursing care is to promote relaxation and provide comfort measures to help the mother cope with contractions and manage pain. This helps create a calm and supportive environment, enhancing the progress of labor. Administering pain medication (A) may be necessary later, not necessarily in the early phase. Monitoring fetal heart rate continuously (B) is important but not the primary goal in the early phase. Preparing for imminent delivery (D) is premature in the early phase, as labor can be lengthy.
A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?
- A. verify the person's immunization history
- B. obtain informed consent
- C. check for signs of an allergic reaction
- D. ensure proper positioning for the vaccine
Correct Answer: D
Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.