Nokea
A nurse is caring for a postpartum person who is at risk for uterine atony. What is the most important action to prevent uterine atony?
- A. administer uterotonic medication
- B. perform uterine massage
- C. perform a vaginal exam
- D. monitor the baby's latch
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. Uterine massage helps the uterus contract, reducing the risk of uterine atony by promoting uterine tone and preventing excessive bleeding. It is crucial in preventing postpartum hemorrhage. Administering uterotonic medications (choice A) can also help prevent uterine atony but is not the most important initial action. Performing a vaginal exam (choice C) is not necessary to prevent uterine atony. Monitoring the baby's latch (choice D) is unrelated to preventing uterine atony.
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A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate?
- A. That is very exciting. The baby must be very healthy.
- B. Would you please describe what you felt for me?
- C. That is impossible. The baby is not big enough yet.
- D. Would you please let me see if I can feel the baby?
Correct Answer: B
Rationale: At 10 weeks, fetal movement is unlikely to be felt. The nurse should ask the client to describe what she felt to determine if it was indeed fetal movement or another sensation.
After nutrition counseling, a woman, G3 P1101, proclaims that she certainly can’t eat any strawberries during her pregnancy. Which of the following is the likely reason for this statement?
- A. The woman is allergic to strawberries.
- B. Strawberries have been shown to cause birth defects.
- C. The woman believes in old wives’ tales.
- D. The premature baby died because the woman ate strawberries.
Correct Answer: A
Rationale: Food allergies are a plausible reason for avoiding strawberries. There is no scientific evidence linking strawberries to birth defects or premature death. Old wives’ tales might exist but are less likely the primary reason here.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during the pushing phase?
- A. assist the person into a squatting position
- B. instruct the person to push with contractions
- C. coach the person through controlled pushing
- D. prepare for spontaneous delivery
Correct Answer: D
Rationale: The correct answer is D: prepare for spontaneous delivery. During the pushing phase of the second stage of labor, the most appropriate nursing intervention is to prepare for the spontaneous delivery of the baby. This involves ensuring that all necessary equipment and supplies are ready for the delivery, positioning oneself appropriately to assist with the birth, and being prepared to provide immediate care to the newborn. This intervention is crucial to ensure a safe and smooth delivery process.
Choice A (assist the person into a squatting position) may not be appropriate for all laboring individuals and may not facilitate the most effective pushing efforts. Choice B (instruct the person to push with contractions) is a general instruction that may not encompass all the necessary aspects of supporting the delivery process. Choice C (coach the person through controlled pushing) may be too restrictive and not allow for the natural progression of labor. Thus, the most appropriate intervention is to prepare for spontaneous delivery to ensure readiness and safety for both the laboring person and the newborn.
When analyzing the need for health teaching of a prenatal multigravida, the nurse should ask which of the following questions?
- A. What are the ages of your children?
- B. What is your marital status?
- C. Do you ever drink alcohol?
- D. Do you have any allergies?
Correct Answer: C
Rationale: Asking about alcohol consumption is directly related to health teaching needs, as it can impact fetal development. The other questions, while important, are not directly related to health teaching.
The nurse is counseling a female patient about alcohol use during pregnancy. Which statement by the patient demonstrates successful patient teaching?
- A. I will limit my drinking to just one alcoholic beverage per day.
- B. It's best for my baby if I avoid drinking during pregnancy.
- C. An occasional drink on special occasions is okay.
- D. Drinking alcohol is only acceptable in the first trimester.
Correct Answer: B
Rationale: The correct answer is B because complete abstinence from alcohol is the safest option during pregnancy to prevent any potential harm to the fetus. This statement shows understanding of the importance of avoiding alcohol for the well-being of the baby. Choice A suggests drinking daily, which can still pose risks. Choice C implies occasional drinking is acceptable, which can still be harmful. Choice D is incorrect because alcohol should be avoided throughout pregnancy, not just in the first trimester.