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A nurse is caring for a postpartum person who is at risk for infection. What is the most important nursing intervention to reduce the risk of infection?
- A. Monitor vital signs
- B. Educate on proper hygiene
- C. Educate on wound care
- D. Encourage ambulation
Correct Answer: A
Rationale: The correct answer is A: Monitor vital signs. This is the most important intervention because changes in vital signs can indicate the presence of infection early on. By closely monitoring the postpartum person's vital signs, the nurse can promptly identify any signs of infection and initiate appropriate interventions. Educating on proper hygiene (B) and wound care (C) are essential but monitoring vital signs takes precedence in immediate infection detection. Encouraging ambulation (D) is beneficial for preventing complications like blood clots, but it is not the most crucial intervention for infection prevention in this scenario.
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How long should clamping of the cord be delayed in an uncomplicated delivery to increase the newborn's hemoglobin levels and improve circulation?
- A. 30–60 seconds
- B. 15–30 seconds
- C. 30 seconds
- D. Delayed cord clamping is not recommended.
Correct Answer: A
Rationale: The correct answer is A (30-60 seconds) for delayed cord clamping in an uncomplicated delivery. Delaying cord clamping for 30-60 seconds allows more blood to flow from the placenta to the baby, increasing the baby's hemoglobin levels and improving circulation. This extra blood transfer can provide the baby with essential nutrients and oxygen, reducing the risk of anemia and improving overall health outcomes.
Choice B (15-30 seconds) may not provide enough time for sufficient blood transfer compared to the optimal window of 30-60 seconds.
Choice C (30 seconds) is within the recommended range, but 30-60 seconds is considered more beneficial for maximizing blood flow to the newborn.
Choice D (Delayed cord clamping is not recommended) is incorrect as delayed cord clamping has been shown to have various benefits for newborns when done in uncomplicated deliveries.
The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not?
- A. 10%
- B. 25%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.
A nurse is caring for a postpartum person who is experiencing excessive bleeding. What should the nurse assess first?
- A. perform uterine massage
- B. perform a vaginal examination
- C. evaluate blood loss
- D. perform a uterine check
Correct Answer: A
Rationale: The correct answer is A: perform uterine massage. This is the priority because uterine massage helps to stimulate uterine contractions, which can help control bleeding in postpartum individuals. It is crucial to address the source of bleeding first. Performing a vaginal examination (choice B) may exacerbate bleeding. Evaluating blood loss (choice C) is important but not the initial step. Performing a uterine check (choice D) is vague and not as specific as uterine massage in addressing postpartum bleeding.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and is experiencing a sudden increase in vaginal discharge. What is the nurse's priority action?
- A. Check for signs of labor and assess fetal heart rate.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Perform a pelvic exam to assess the amount of discharge.
- D. Call the healthcare provider immediately to report the change in discharge.
Correct Answer: A
Rationale: The correct answer is A because the sudden increase in vaginal discharge at 40 weeks gestation could indicate the onset of labor. Checking for signs of labor, such as contractions and assessing fetal heart rate, is crucial to determine if the patient is in active labor. This helps in timely intervention and ensuring the well-being of both the mother and baby.
Summary:
- Choice B: Encouraging rest and monitoring changes in discharge may not address the urgency of the situation.
- Choice C: Performing a pelvic exam without assessing signs of labor or fetal well-being may delay necessary actions.
- Choice D: While reporting to the healthcare provider is important, immediate assessment of labor signs and fetal heart rate takes precedence.
A pregnant patient is 32 weeks gestation and reports having trouble sleeping. Which of the following interventions should the nurse recommend?
- A. Take a warm bath and avoid using any pillows.
- B. Sleep on your back to relieve pressure on the uterus.
- C. Sleep with several pillows to elevate the upper body.
- D. Take sedatives to ensure a good night's sleep.
Correct Answer: C
Rationale: The correct answer is C: Sleep with several pillows to elevate the upper body. Elevating the upper body with pillows can help relieve discomfort from heartburn, shortness of breath, and back pain commonly experienced during pregnancy. This position promotes better circulation and reduces pressure on the uterus.
Incorrect choices:
A: Taking a warm bath may help relax but does not address the underlying sleep issues.
B: Sleeping on the back can compress major blood vessels, leading to decreased blood flow to the fetus.
D: Taking sedatives is not recommended during pregnancy due to potential risks to the fetus.