Nokea
A nurse is caring for a postpartum person who is experiencing a headache. What is the most likely cause of a postpartum headache?
- A. Eclampsia
- B. Spinal headache
- C. Tension headache
- D. Cluster headache
Correct Answer: B
Rationale: The correct answer is B: Spinal headache. Postpartum spinal headaches are commonly caused by leakage of cerebrospinal fluid due to accidental dural puncture during epidural anesthesia. This can lead to severe headaches that worsen when sitting or standing. Eclampsia (A) presents with hypertension and seizures, not just headaches. Tension headaches (C) are typically stress-related and not specific to the postpartum period. Cluster headaches (D) are characterized by severe pain around the eye and are not commonly associated with childbirth.
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A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse’s most appropriate response?
- A. The test results are within normal limits.
- B. Immediate birth by cesarean birth is being considered.
- C. Further testing will be performed to determine the meaning of this score.
- D. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.
Correct Answer: A
Rationale: A score of 8-10 is within the normal range for a biophysical profile, indicating no immediate concerns for the fetus.
What is the primary purpose of performing an episiotomy during delivery?
- A. to reduce the risk of perineal trauma
- B. to promote faster delivery
- C. to facilitate fetal descent
- D. to provide immediate fetal oxygenation
Correct Answer: A
Rationale: The primary purpose of performing an episiotomy during delivery is to reduce the risk of perineal trauma. Episiotomy is a surgical incision made in the perineum to widen the vaginal opening during childbirth, which can help prevent severe tearing of the perineal tissue. This procedure is performed to provide controlled and precise incision, reducing the likelihood of extensive tears that may lead to complications such as infection or prolonged healing time. It is not done to promote faster delivery, facilitate fetal descent, or provide immediate fetal oxygenation. These choices do not accurately reflect the main goal of episiotomy, which is to minimize perineal trauma.
What organ does the ductus venosus shunt blood away from in fetal circulation?
- A. Liver
- B. Heart
- C. Lungs
- D. Kidneys
Correct Answer: A
Rationale: Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.
A nurse is assisting with a vaginal birth. What is the most appropriate nursing action when the head crowns during delivery?
- A. apply gentle pressure to the fetal head
- B. prepare for delivery of the placenta
- C. assist with shoulder delivery
- D. apply gentle pressure to the perineum
Correct Answer: A
Rationale: The correct answer is A: apply gentle pressure to the fetal head. This action helps prevent rapid delivery, reducing the risk of perineal tearing and promoting controlled delivery of the baby. Applying pressure also helps prevent the baby from being born too quickly, reducing the risk of umbilical cord compression and potential birth injuries.
Choices B, C, and D are incorrect because at the moment the head crowns, the priority is to assist with the controlled delivery of the baby's head. Delivering the placenta (B) and assisting with shoulder delivery (C) are steps that come after the baby's head is delivered. Applying pressure to the perineum (D) is not recommended as it may increase the risk of perineal tearing.
A nurse is caring for a postpartum person who is experiencing excessive bleeding. What should the nurse assess first?
- A. perform uterine massage
- B. perform a vaginal examination
- C. evaluate blood loss
- D. perform a uterine check
Correct Answer: A
Rationale: The correct answer is A: perform uterine massage. This is the priority because uterine massage helps to stimulate uterine contractions, which can help control bleeding in postpartum individuals. It is crucial to address the source of bleeding first. Performing a vaginal examination (choice B) may exacerbate bleeding. Evaluating blood loss (choice C) is important but not the initial step. Performing a uterine check (choice D) is vague and not as specific as uterine massage in addressing postpartum bleeding.