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A nurse is caring for a postpartum person with a second-degree perineal tear. What is the most appropriate intervention for pain management?
- A. administer oral pain medication
- B. administer an epidural analgesic
- C. administer non-pharmacological pain relief
- D. administer ice packs
Correct Answer: C
Rationale: The most appropriate intervention for pain management in a postpartum person with a second-degree perineal tear is administering non-pharmacological pain relief (Choice C). This includes methods such as sitz baths, warm compresses, and positioning techniques. These interventions are effective in reducing pain and promoting healing without the side effects associated with medications or invasive procedures. Oral pain medication (Choice A) may not be sufficient for managing the specific pain in this case. Administering an epidural analgesic (Choice B) is not appropriate postpartum, as it is typically used during labor for pain relief. Ice packs (Choice D) may provide temporary relief but do not address the underlying pain and healing process as effectively as non-pharmacological methods.
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An 18-week gestation client telephones the obstetrician’s office stating, 'I’m really scared. I think I have breast cancer. My breasts are filled with tumors.' The nurse should base the response on which of the following?
- A. Breast cancer is often triggered by pregnancy.
- B. Nodular breast tissue is normal during pregnancy.
- C. The woman is exhibiting signs of a psychotic break.
- D. Anxiety attacks are especially common in the second trimester.
Correct Answer: B
Rationale: Nodular breast tissue is a normal change during pregnancy due to hormonal fluctuations. Breast cancer is not typically triggered by pregnancy, and anxiety attacks are not specifically common in the second trimester.
A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
A pregnant patient is at 28 weeks gestation and reports leg cramps. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to stretch the legs and elevate them to alleviate the cramps.
- B. Recommend that the patient increase calcium intake through dietary changes.
- C. Administer prescribed pain medication to relieve discomfort.
- D. Encourage the patient to walk for 30 minutes each day to prevent cramps.
Correct Answer: A
Rationale: The correct answer is A. Leg cramps during pregnancy are common due to increased weight and pressure on leg muscles. Stretching and elevating legs can help alleviate cramps by improving circulation and reducing muscle tension. Increasing calcium intake (B) may help prevent cramps but is not the immediate action needed. Administering pain medication (C) should be avoided unless absolutely necessary. Walking (D) is beneficial for overall health during pregnancy but may not directly address the immediate leg cramps.
A nurse is caring for a pregnant patient who is 28 weeks gestation and has been diagnosed with gestational diabetes. What is the nurse's priority teaching for this patient?
- A. Encourage the patient to exercise vigorously to manage blood sugar levels.
- B. Monitor blood glucose levels regularly and follow a balanced diet.
- C. Instruct the patient to limit fluid intake to prevent complications.
- D. Recommend insulin therapy immediately to control blood sugar levels.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose levels regularly and follow a balanced diet. This is the priority teaching for a pregnant patient with gestational diabetes because it focuses on managing blood sugar levels effectively. Regular monitoring helps the patient understand how their body responds to different foods and activities. Following a balanced diet helps maintain stable blood sugar levels and provides essential nutrients for the baby's development.
A: Encouraging vigorous exercise may not be safe during pregnancy, especially for a patient with gestational diabetes.
C: Limiting fluid intake is not a priority teaching for gestational diabetes and may lead to dehydration, which can be harmful during pregnancy.
D: Recommending insulin therapy immediately is not the first-line treatment for gestational diabetes. Lifestyle modifications like diet and exercise are usually tried first.
The nurse is educating a pregnant patient about the symptoms of preterm labor. Which of the following symptoms should the nurse advise the patient to report immediately?
- A. Occasional low back pain and cramping
- B. Increased vaginal discharge
- C. Painful, regular contractions every 10 minutes or less
- D. Feeling of pelvic pressure after physical activity
Correct Answer: C
Rationale: Step-by-step rationale:
1. Painful, regular contractions every 10 minutes or less can indicate preterm labor.
2. Regular contractions are a sign of the uterus preparing for birth.
3. Painful contractions at regular intervals can progress quickly to preterm delivery.
4. Reporting this symptom immediately allows for timely intervention to prevent premature birth.
Summary:
A: Low back pain and cramping are common in pregnancy but not necessarily indicative of preterm labor.
B: Increased vaginal discharge may be normal in pregnancy and not a direct sign of preterm labor.
C: Painful, regular contractions every 10 minutes or less are a critical sign of preterm labor.
D: Feeling pelvic pressure after physical activity is common in late pregnancy and not specific to preterm labor.