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A nurse is caring for a postpartum person who is experiencing excessive bleeding. What is the first step in managing postpartum hemorrhage?
- A. administer uterotonics
- B. administer IV fluids
- C. perform a manual removal of the placenta
- D. monitor vital signs every 15 minutes
Correct Answer: A
Rationale: The correct answer is A: administer uterotonics. Uterotonics help to contract the uterus, which can help stop the bleeding in postpartum hemorrhage. This is the initial step in managing postpartum hemorrhage to address the primary cause of excessive bleeding. Administering IV fluids (B) can support circulation but does not address the underlying issue. Performing manual removal of the placenta (C) is invasive and not the first-line treatment for postpartum hemorrhage. Monitoring vital signs (D) is important but should not delay the immediate intervention of administering uterotonics.
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A nurse is caring for a laboring person who is experiencing fetal tachycardia. What is the most appropriate intervention?
- A. administer oxygen
- B. administer IV fluids
- C. monitor maternal vital signs
- D. monitor fetal heart rate continuously
Correct Answer: A
Rationale: Correct Answer: A: Administer oxygen
Rationale: Fetal tachycardia indicates the fetus is not getting enough oxygen. Administering oxygen to the laboring person will help increase oxygen levels in their blood, leading to better oxygen supply to the fetus and potentially improving the fetal heart rate.
Summary of Other Choices:
B: Administering IV fluids may be helpful in some cases, but it is not the priority when dealing with fetal tachycardia.
C: While monitoring maternal vital signs is important, addressing the fetal tachycardia and oxygen supply to the fetus takes precedence.
D: Continuous monitoring of fetal heart rate is essential, but administering oxygen should be the immediate intervention to address the underlying issue of oxygen deficiency.
A nurse is caring for a laboring person who is in the third stage of labor. What is the most appropriate nursing intervention during this stage?
- A. assist with the delivery of the placenta
- B. prepare for a vaginal birth
- C. administer oxytocin
- D. apply gentle pressure to the uterus
Correct Answer: A
Rationale: The correct answer is A: assist with the delivery of the placenta. During the third stage of labor, the placenta needs to be delivered. This is done by gently applying traction to the umbilical cord while supporting the uterus to facilitate the expulsion of the placenta. This step is crucial to prevent postpartum hemorrhage.
Choice B (prepare for a vaginal birth) is incorrect because the person is already in the third stage of labor, which means the baby has been delivered and they are now focusing on delivering the placenta.
Choice C (administer oxytocin) is incorrect because while oxytocin may be used to help control bleeding after the placenta is delivered, it is not the most appropriate intervention during the third stage of labor.
Choice D (apply gentle pressure to the uterus) is incorrect because direct pressure to the uterus is not the primary intervention during the third stage of labor; assisting with the delivery of the placenta takes precedence.
A 38-week gestation client, Bishop score 1, is advised by her nurse midwife to take evening primrose daily. The office nurse advises the client to report which of the following side effects that has been attributed to the oil?
- A. Diarrhea.
- B. Pedal edema.
- C. Blurred vision.
- D. Tinnitus.
Correct Answer: A
Rationale: Diarrhea is a known side effect of evening primrose oil. Pedal edema, blurred vision, and tinnitus are not typically associated with its use.
The nurse is educating a pregnant patient about the importance of exercise during pregnancy. Which statement by the patient indicates that the teaching has been effective?
- A. I should avoid any exercise because it could harm my baby.
- B. Moderate exercise is safe and helps prepare my body for labor.
- C. I should only exercise during the second trimester to avoid complications.
- D. I can perform any type of exercise as long as I am comfortable.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the importance of moderate exercise during pregnancy to prepare the body for labor. This shows understanding of the benefits of exercise for both the mother and baby. Choice A is incorrect as it promotes complete avoidance of exercise, which is not recommended. Choice C is incorrect because exercise is beneficial throughout pregnancy, not just in the second trimester. Choice D is incorrect because some exercises may not be safe during pregnancy, so comfort alone is not the only factor to consider.
The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods?
- A. Tofu, legumes, broccoli.
- B. Corn, yams, green beans.
- C. Potatoes, parsnips, turnips.
- D. Cheese, yogurt, fish.
Correct Answer: A
Rationale: Tofu, legumes, and broccoli provide essential nutrients like protein, iron, and calcium that are often lacking in a vegan diet. Corn, yams, and green beans offer carbohydrates and vitamins but lack sufficient protein sources. Potatoes, parsnips, and turnips are starchy vegetables with limited nutritional variety. Cheese, yogurt, and fish are non-vegan options.