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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 important intervention to prevent DVT?
- A. administer anticoagulants
- B. administer IV fluids
- C. perform leg exercises
- D. ensure early ambulation
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate hydration which prevents blood from becoming too thick and reduces the risk of clot formation. Adequate hydration also promotes blood circulation, decreasing the risk of DVT. Administering anticoagulants (choice A) is important in managing DVT but is not the most important preventive intervention. Performing leg exercises (choice C) and ensuring early ambulation (choice D) are also beneficial in preventing DVT, but maintaining hydration with IV fluids is the most crucial intervention as it directly addresses the primary factor contributing to DVT formation.
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A patient at 36 weeks gestation is undergoing a nonstress test (NST). The nurse observes the fetal heart rate baseline at 135 bpm and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for 20-25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: An NST is reactive and reassuring when two or more accelerations occur within 20 minutes, indicating fetal well-being.
A woman in labor is receiving magnesium sulfate for preterm labor. What should the nurse monitor closely during this treatment?
- A. Deep tendon reflexes
- B. Respiratory rate
- C. Maternal blood pressure
- D. Fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes. Magnesium sulfate can cause muscle weakness and respiratory depression due to its effect on the central nervous system. Monitoring deep tendon reflexes helps assess for magnesium toxicity. Respiratory rate (B) should also be monitored, but it is not the most critical parameter for magnesium sulfate. Maternal blood pressure (C) is important, but changes are usually gradual and not directly related to magnesium sulfate. Fetal heart rate (D) is crucial, but in this case, the focus should be on the mother's response to the medication.
The nurse is interviewing a 38-week gestation Muslim woman.
- A. Do you plan to breastfeed your baby?
- B. What do you plan to name the baby?
- C. Which pediatrician do you plan to use?
- D. How do you feel about having an episiotomy?
Correct Answer: D
Rationale: Questions about episiotomy might be culturally sensitive or inappropriate without prior discussion of preferences, especially in certain cultural contexts like Islam.
The nurse is caring for a 32-year-old pregnant patient who is 20 weeks gestation and has a BMI of 40. Which of the following conditions should the nurse monitor for more closely?
- A. Gestational diabetes and preeclampsia
- B. Hyperemesis gravidarum
- C. Iron-deficiency anemia
- D. Intrauterine growth restriction (IUGR)
Correct Answer: A
Rationale: The correct answer is A: Gestational diabetes and preeclampsia. A BMI of 40 indicates obesity, which increases the risk of developing gestational diabetes and preeclampsia. Obesity is a significant risk factor for these conditions due to the increased strain on the body during pregnancy. Gestational diabetes can lead to complications for both the mother and the baby, while preeclampsia can be life-threatening if not managed properly. Monitoring for these conditions closely is crucial in this high-risk patient.
Incorrect Choices:
B: Hyperemesis gravidarum - This condition is characterized by severe nausea and vomiting during pregnancy and is not directly related to the patient's BMI.
C: Iron-deficiency anemia - While obesity can impact iron levels, it is not the primary concern in this scenario.
D: Intrauterine growth restriction (IUGR) - While obesity can increase the risk of certain pregnancy complications, IUGR is not directly linked to the patient's
A nurse is educating a postpartum person about newborn care. Which of the following should be included in the teaching about umbilical cord care?
- A. keep the cord dry and clean
- B. apply a sterile dressing to the cord
- C. use alcohol or iodine to clean the cord
- D. apply a sterile dressing to the umbilicus
Correct Answer: A
Rationale: The correct answer is A: keep the cord dry and clean. This is because keeping the umbilical cord dry and clean helps prevent infection and promotes healing. Applying a sterile dressing (B) is unnecessary and may trap moisture, leading to infection. Using alcohol or iodine (C) is outdated and can delay cord separation. Applying a sterile dressing to the umbilicus (D) is not recommended as it can interfere with air circulation and healing. In summary, choice A is correct as it aligns with current best practices for umbilical cord care.