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A nurse is caring for a postpartum person who is breastfeeding. What is the most important factor for successful breastfeeding?
- A. frequent breastfeeding
- B. proper positioning
- C. supportive communication
- D. promote rest and hydration
Correct Answer: B
Rationale: The correct answer is B: proper positioning. Proper positioning is crucial for successful breastfeeding as it ensures the baby latches on effectively, leading to efficient milk transfer and preventing nipple pain or damage. Incorrect answers:
A: frequent breastfeeding - While important, proper positioning is more critical for successful breastfeeding.
C: supportive communication - While important for overall well-being, it is not the most crucial factor for successful breastfeeding.
D: promote rest and hydration - While important for the postpartum person's health, proper positioning is key for successful breastfeeding.
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A pregnant patient at 26 weeks gestation reports nausea and vomiting. What is the nurse's priority action?
- A. Administer anti-nausea medications as prescribed.
- B. Instruct the patient to eat larger meals less frequently.
- C. Encourage the patient to eat smaller, more frequent meals and avoid greasy foods.
- D. Encourage the patient to rest and avoid physical activity.
Correct Answer: C
Rationale: The correct answer is C because nausea and vomiting are common during pregnancy and can be alleviated by eating smaller, more frequent meals and avoiding greasy foods. This strategy helps maintain stable blood sugar levels and reduces gastric distress. Administering anti-nausea medications (A) should only be considered if conservative measures fail. Instructing the patient to eat larger meals less frequently (B) may worsen symptoms. Encouraging rest and avoiding physical activity (D) may be beneficial but addressing dietary factors is the priority in this case.
A nurse is educating a pregnant patient about the signs of preterm labor. Which of the following should the nurse include in the teaching plan?
- A. Frequent, regular contractions every 10 minutes or less.
- B. Decreased fetal movement and back pain.
- C. Mild cramping and occasional vaginal spotting.
- D. Headaches and blurred vision, especially after physical activity.
Correct Answer: A
Rationale: The correct answer is A because frequent, regular contractions every 10 minutes or less are a classic sign of preterm labor, indicating the need for immediate medical attention. Decreased fetal movement and back pain (choice B) are not specific signs of preterm labor. Mild cramping and occasional vaginal spotting (choice C) could be normal in pregnancy or may indicate other issues, but they are not definitive signs of preterm labor. Headaches and blurred vision (choice D) are more indicative of preeclampsia, a separate condition from preterm labor. Therefore, choice A is the most accurate and specific sign to include in the teaching plan for preterm labor.
A patient with gestational hypertension is being monitored during labor. What is the most important factor to assess?
- A. Fetal heart rate
- B. Blood pressure
- C. Uterine contractions
- D. Fetal malpresentation
Correct Answer: B
Rationale: The correct answer is B: Blood pressure. In a patient with gestational hypertension, monitoring blood pressure is crucial to assess for worsening hypertension, which can lead to complications such as preeclampsia and eclampsia. Elevated blood pressure can affect both maternal and fetal well-being. Assessing fetal heart rate (A) is important but not the most critical factor in this scenario. Uterine contractions (C) are important but secondary to monitoring blood pressure. Fetal malpresentation (D) can impact delivery but is not the most vital factor to assess in a patient with gestational hypertension.
A client makes the following statement after finding out that her pregnancy test is positive, 'This is not a good time. I am in college and the baby will be due during final exams!' Which of the following responses by the nurse would be most appropriate at this time?
- A. I’m absolutely positive that everything will turn out all right.
- B. I suggest that you e-mail your professors to set up an alternate plan.
- C. It sounds like you’re feeling a little overwhelmed right now.
- D. You and the baby’s father will find a way to get through the pregnancy.
Correct Answer: C
Rationale: Acknowledging the client's feelings of being overwhelmed is the most supportive response. Offering solutions or reassurance without first addressing the client's emotions may not be as effective.
A nurse is caring for a postpartum person during the fourth stage of labor. The nurse is assessing uterine involution to ensure that the uterus is returning to its prepregnancy size and position. Which finding is indicative of normal uterine involution during this stage?
- A. Uterus is palpable at the level of the umbilicus.
- B. Uterine fundus is firm, at the level of the umbilicus.
- C. Uterus is displaced to the right side of the abdomen.
- D. Uterus is above the level of the umbilicus.
Correct Answer: B
Rationale: The correct answer is B because during the fourth stage of labor, the uterine fundus should be firm and at the level of the umbilicus. This indicates proper involution as the uterus is contracting and reducing in size. Choice A is incorrect as the uterus should not be palpable at the level of the umbilicus during normal involution. Choice C is incorrect as the uterus should not be displaced to the right side of the abdomen. Choice D is incorrect as the uterus should not be above the level of the umbilicus, as this would suggest inadequate involution.