External Maternal Monitoring

External Maternal Monitoring Related

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A nurse is caring for a postpartum person who is breastfeeding. What is the most important intervention to prevent nipple trauma?

  • A. assist with breastfeeding positioning
  • B. offer pain relief
  • C. apply a cold compress
  • D. monitor contractions
Correct Answer: B

Rationale: The correct answer is B: offer pain relief. Providing pain relief is crucial in preventing nipple trauma as it can help the postpartum person tolerate any discomfort associated with breastfeeding, thereby reducing the likelihood of damage to the nipples. Assisting with breastfeeding positioning (choice A) is important but not as critical as pain relief. Applying a cold compress (choice C) may help with inflammation but does not directly address the pain during breastfeeding. Monitoring contractions (choice D) is unrelated to preventing nipple trauma. Ultimately, addressing pain relief is the most effective intervention in ensuring successful and comfortable breastfeeding, thus preventing nipple trauma.

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What complication is associated with pica during pregnancy?

  • A. Hypothyroidism
  • B. Iron-deficiency anemia
  • C. Hypercalcemia
  • D. Overexposure to zinc
Correct Answer: B

Rationale: Pica often leads to nutritional deficiencies, particularly iron-deficiency anemia, due to the ingestion of non-food substances.

The nurse is educating the pregnant patient with a body mass index (BMI) of 33. The nurse knows that teaching has been effective when the patient states which of the following?

  • A. My child may be at increased risk for birth injury.
  • B. My child may have a decreased risk of developing childhood diabetes.
  • C. I will probably give birth vaginally.
  • D. I have a lower risk of developing gestational hypertension.
Correct Answer: A

Rationale: The correct answer is A: "My child may be at increased risk for birth injury." This is correct because a pregnant patient with a BMI of 33 is considered obese, which can increase the risk of birth injury to the baby due to complications such as macrosomia (large birth weight).

Explanation:
1. Obesity in pregnancy can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
2. Higher BMI can also increase the risk of cesarean delivery, which may be necessary to prevent birth injuries.
3. Childhood diabetes risk is not decreased with maternal obesity.
4. Mode of delivery (vaginal or cesarean) is not solely determined by BMI.
5. Gestational hypertension risk is actually higher in women with obesity.

In summary, choice A is correct because it directly relates to the increased risk of birth injury associated with maternal obesity, while the other choices are not directly linked to the patient's BMI and pregnancy complications.

The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?

  • A. Hemophilia
  • B. Sickle cell anemia
  • C. A neural tube defect
  • D. Abnormal lecithin-to-sphingomyelin ratio
Correct Answer: C

Rationale: An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter maternal serum, indicating a neural tube defect.

What is the purpose of initiating contractions in a contraction stress test (CST)?

  • A. Increase placental blood flow.
  • B. Identify fetal acceleration patterns.
  • C. Determine the degree of fetal activity.
  • D. Apply a stressful stimulus to the fetus.
Correct Answer: D

Rationale: The CST assesses fetal response to the stress of uterine contractions to determine if the fetus can tolerate labor.

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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