Nokea
A nurse is caring for a postpartum person who is at risk for uterine atony. What is the most important intervention to prevent uterine atony?
- A. administer uterotonic medications
- B. perform fundal massage
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: B
Rationale: The correct answer is B: perform fundal massage. Fundal massage helps stimulate uterine contractions and prevents uterine atony by promoting uterine firmness and reducing the risk of excessive bleeding. It is a non-invasive intervention that can be done immediately after delivery to prevent postpartum hemorrhage. Administering uterotonic medications (Choice A) may be necessary in severe cases but fundal massage is the initial intervention. Performing a vaginal exam (Choice C) is not indicated unless there are specific concerns or indications. Monitoring vital signs (Choice D) is important but addressing uterine atony requires more direct intervention like fundal massage.
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A pregnant patient is at 34 weeks gestation and reports frequent headaches and visual changes. What should the nurse do first?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Encourage the patient to rest and drink plenty of fluids.
- C. Administer pain medication as prescribed to relieve the headache.
- D. Schedule an appointment with an eye specialist to check for vision changes.
Correct Answer: A
Rationale: The correct answer is A. At 34 weeks gestation, headaches and visual changes can be signs of preeclampsia, a serious pregnancy complication. The nurse should first monitor the patient's blood pressure as elevated BP is a key indicator of preeclampsia. Assessing for other signs like proteinuria and edema is crucial for early detection and timely intervention. Encouraging rest and fluids (choice B) may not address the underlying issue. Administering pain medication (choice C) only masks symptoms without addressing the potential serious condition. Scheduling an eye specialist appointment (choice D) is not the priority as the symptoms are more indicative of a systemic issue like preeclampsia.
Which statement about fetal circulation is correct?
- A. The foramen ovale is between ventricles
- B. Umbilical vein contains oxygen-poor blood
- C. Right atrium contains mixed blood
- D. Ductus venosus lies between aorta and pulmonary artery
Correct Answer: C
Rationale: The right atrium contains both oxygen-rich and oxygen-poor blood due to the unique fetal circulatory system.
A 20-year-old client states that the at-home pregnancy test that she took this morning was positive. Which of the following comments by the nurse is appropriate at this time?
- A. Congratulations, you and your family must be so happy.
- B. Have you told the baby’s father yet?
- C. How do you feel about the results?
- D. Please tell me when your last menstrual period was.
Correct Answer: C
Rationale: It is important to assess the client's emotional response to the pregnancy test result before providing further guidance or congratulations.
The woman's partner is lightly stroking her abdomen as an alternative to medication for pain relief in labor. What is this known as?
- A. Counterpressure
- B. Effieurage
- C. Guided imagery
- D. Biofeedback
Correct Answer: A
Rationale: The correct answer is A: Counterpressure. This technique involves applying pressure to specific areas to alleviate pain during labor. In this scenario, the partner is using light strokes on the woman's abdomen to provide pain relief. Counterpressure helps release endorphins, which are natural painkillers, and distracts the brain from focusing on the pain sensations. Effleurage (B) is a gentle stroking technique used for relaxation, not specifically for pain relief. Guided imagery (C) involves visualizing calming scenes to reduce stress, not directly addressing pain. Biofeedback (D) is a method of monitoring and controlling physiological responses, not a hands-on pain relief technique like counterpressure.
A pregnant patient at 26 weeks gestation reports frequent headaches and blurred vision. What should the nurse do first?
- A. Encourage the patient to take over-the-counter pain medication for relief.
- B. Monitor the patient's blood pressure and check for signs of preeclampsia.
- C. Advise the patient to rest and stay hydrated to alleviate symptoms.
- D. Schedule a follow-up appointment for further evaluation in a few days.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure and check for signs of preeclampsia. At 26 weeks gestation, headaches and blurred vision could be symptoms of preeclampsia, a serious condition in pregnancy. Monitoring blood pressure is crucial as high blood pressure is a key indicator. Preeclampsia can lead to severe complications for both the mother and baby if left untreated. Encouraging over-the-counter pain medication (Choice A) may mask symptoms without addressing the underlying cause. Rest and hydration (Choice C) are important, but immediate evaluation for preeclampsia is necessary. Scheduling a follow-up appointment (Choice D) delays potential diagnosis and treatment.