Nokea
A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?
- A. apply warm compresses
- B. apply cold compresses
- C. provide distraction techniques
- D. apply lanolin cream
Correct Answer: B
Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.
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A patient who was admitted to the delivery room undergoes an ultrasound, which reveals that the sacrum is the presenting part; the lie is longitudinal, with both the hips and knees in flexion. Which describes this fetal presentation?
- A. Cephalic
- B. Complete breech
- C. Frank breech
- D. Footling breech
Correct Answer: C
Rationale: The correct answer is A: Cephalic. In this presentation, the sacrum is the presenting part, indicating the baby is head down, which is characteristic of a cephalic presentation. Additionally, the lie is longitudinal, further supporting the cephalic presentation. The flexion of both hips and knees is also consistent with the normal positioning of a baby in the cephalic presentation.
Summary of other choices:
B: Complete breech - In a complete breech presentation, the baby is bottom down with both hips and knees flexed, but the sacrum would not be the presenting part.
C: Frank breech - In a frank breech presentation, the baby's buttocks are the presenting part with the legs extended and the feet near the head.
D: Footling breech - In a footling breech presentation, one or both feet are the presenting part, with the hips and knees extended, not flexed as described in the scenario.
Which of the following is an appropriate intervention for a birthing person experiencing preterm labor?
- A. administer tocolytics
- B. administer antibiotics
- C. provide hydration and rest
- D. offer pain relief
Correct Answer: A
Rationale: The correct answer is A: administer tocolytics. Tocolytics help inhibit uterine contractions and can delay preterm labor, giving time for other interventions. Administering antibiotics (B) would not directly address preterm labor. Providing hydration and rest (C) may be helpful but not a direct intervention. Offering pain relief (D) does not address the underlying cause of preterm labor. Administering tocolytics is crucial in managing preterm labor to prevent premature birth and associated complications.
A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
A nurse is assessing a laboring person for signs of fetal distress. What is the most common sign of fetal distress?
- A. increase oxygen flow
- B. tachycardia
- C. bradycardia
- D. irregular fetal heart rate
Correct Answer: B
Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.
What complication can result from untreated respiratory distress in the newborn?
- A. Esophageal atresia
- B. Gastric dilation
- C. Cold stress
- D. Reopening of the foramen ovale
Correct Answer: D
Rationale: Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.