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A nurse is caring for a postpartum person who is breastfeeding. What is the most important action to support successful breastfeeding?
- A. educate the person on proper latch
- B. support skin-to-skin contact
- C. promote frequent feeding
- D. educate on postpartum care
Correct Answer: B
Rationale: The correct answer is B: support skin-to-skin contact. Skin-to-skin contact immediately after birth helps regulate the baby's body temperature, promotes bonding, and enhances breastfeeding success by stimulating the baby's natural instincts to latch on and feed. This action establishes a strong foundation for successful breastfeeding.
Rationale:
1. Skin-to-skin contact promotes bonding and attachment between the parent and baby, creating a supportive environment for breastfeeding.
2. It helps regulate the baby's body temperature, ensuring they are comfortable and more willing to breastfeed effectively.
3. Skin-to-skin contact triggers the baby's natural feeding reflexes, making it easier for them to latch on properly.
4. This action fosters a positive breastfeeding experience for both the parent and baby, setting the stage for successful breastfeeding.
Summary:
- Choice A: educating on proper latch is important, but skin-to-skin contact is more crucial for establishing successful breastfeeding.
- Choice C: promoting frequent feeding is beneficial, but skin-to
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A laboring person is requesting an epidural for pain relief. What is the most important nursing action before the procedure?
- A. administer an epidural bolus
- B. check for any contraindications
- C. perform a vaginal exam
- D. ensure continuous fetal monitoring
Correct Answer: B
Rationale: The correct answer is B: check for any contraindications. Before administering an epidural, it is crucial to assess for contraindications such as low platelet count, infection at the insertion site, or severe hypotension as these may increase the risk of complications. Administering an epidural bolus (A) without checking for contraindications can be dangerous. Performing a vaginal exam (C) is not necessary before an epidural and could increase the risk of infection. Ensuring continuous fetal monitoring (D) is important during labor but is not the most critical action before administering an epidural.
The nurse is assessing a 38-week pregnant woman who is experiencing severe abdominal pain and has not felt her baby move for several hours. What is the most appropriate action for the nurse to take?
- A. Encourage the patient to drink water and rest.
- B. Notify the healthcare provider immediately.
- C. Ask the patient to lie on her left side and monitor fetal movements.
- D. Reassure the patient that this is common at the end of pregnancy.
Correct Answer: B
Rationale: The correct answer is B: Notify the healthcare provider immediately. This is the most appropriate action because the pregnant woman is experiencing severe abdominal pain and has not felt her baby move for several hours, which could indicate a potential emergency situation such as placental abruption or fetal distress. Prompt notification of the healthcare provider is crucial for timely evaluation and management to ensure the well-being of both the mother and the baby.
Choice A is incorrect because simply encouraging the patient to drink water and rest may delay necessary medical intervention. Choice C is incorrect as monitoring fetal movements without immediate healthcare provider notification may lead to a critical delay in assessment and treatment. Choice D is incorrect as reassuring the patient without further evaluation could overlook a serious issue.
A nurse is caring for a patient in labor who is experiencing intense pain. Which of the following would be the most appropriate intervention to manage pain during labor?
- A. Encourage the patient to practice deep breathing and relaxation techniques.
- B. Administer intravenous fluids to reduce pain sensation.
- C. Provide a sedative to help the patient rest between contractions.
- D. Suggest an epidural to block pain completely.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to practice deep breathing and relaxation techniques. This is the most appropriate intervention to manage pain during labor because deep breathing and relaxation techniques can help the patient to cope with the pain, reduce stress, and promote a sense of control. These techniques are safe, non-invasive, and can be effective in managing labor pain without the need for medication or invasive procedures.
Summary:
- Choice B (Administer intravenous fluids): Intravenous fluids do not directly reduce pain sensation and are not a primary intervention for managing labor pain.
- Choice C (Provide a sedative): Sedatives may affect the baby and can interfere with the progress of labor. They do not address the root cause of pain during labor.
- Choice D (Suggest an epidural): While epidurals can provide effective pain relief, they are not always necessary or desired by all patients. Encouraging non-pharmacological methods first is often preferred.
The nurse has made it a goal to increase the rate at which women begin prenatal care in the first trimester. The nurse relates this decision to national goals for better maternal and infant outcomes. What guidelines will the nurse use to guide her maternal health goals?
- A. WHO Maternal care guidelines
- B. State Practice Acts
- C. AWHONN white papers
- D. Healthy People 2020
Correct Answer: D
Rationale: The correct answer is D: Healthy People 2020. The nurse will use Healthy People 2020 guidelines because they are evidence-based, nationally recognized objectives that focus on improving the health and well-being of individuals, families, and communities. These guidelines specifically address maternal and infant health outcomes, making them the most relevant choice for the nurse's goal.
Incorrect Choices:
A: WHO Maternal care guidelines - While WHO guidelines are important, they are not specific to the national goals and objectives the nurse is trying to align with.
B: State Practice Acts - State Practice Acts govern the scope of practice for nurses and do not provide specific guidelines for maternal health goals.
C: AWHONN white papers - AWHONN provides valuable resources, but they may not be as comprehensive or nationally recognized as Healthy People 2020 for setting maternal health goals.
The nurse is caring for a pregnant patient who is at 25 weeks gestation and is concerned about gestational diabetes. Which of the following symptoms should the nurse educate the patient to watch for?
- A. Increased thirst and frequent urination
- B. Severe leg cramps and dizziness
- C. Constant fatigue and swollen feet
- D. Shortness of breath and dizziness upon standing
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and frequent urination. These symptoms are indicative of gestational diabetes due to elevated blood sugar levels. Increased thirst is a result of the body trying to dilute the excess glucose through increased fluid intake, leading to frequent urination. This occurs because the kidneys work to eliminate the excess glucose from the blood by excreting it in the urine. Therefore, educating the patient to watch for these symptoms is crucial for early detection and management of gestational diabetes.
Choices B, C, and D are incorrect as they do not directly correlate with the symptoms of gestational diabetes. Severe leg cramps and dizziness (Choice B) may be related to other factors such as dehydration or electrolyte imbalance. Constant fatigue and swollen feet (Choice C) could be common symptoms during pregnancy but are not specific to gestational diabetes. Shortness of breath and dizziness upon standing (Choice D) are more likely to be related to issues such as anemia or changes