Nokea
A nurse is caring for a pregnant patient at 32 weeks gestation who is experiencing severe leg cramps. What is the nurse's most appropriate intervention?
- A. Encourage the patient to perform gentle stretching exercises and elevate the legs.
- B. Instruct the patient to take calcium supplements to prevent cramps.
- C. Apply heat or cold packs to the affected area to reduce pain.
- D. Administer pain medications to alleviate discomfort.
Correct Answer: A
Rationale: The correct answer is A because gentle stretching exercises help relieve muscle tension and improve circulation, alleviating leg cramps. Elevating the legs can also help reduce swelling and promote blood flow. Choice B is incorrect because while calcium is essential for muscle function, it is not the primary intervention for acute leg cramps. Choice C may provide temporary relief but does not address the underlying cause of the cramps. Choice D should be avoided in pregnancy unless absolutely necessary due to potential risks to the fetus.
You may also like to solve these questions
The nurse asks a woman about how the woman’s husband is dealing with the pregnancy.
- A. My husband is ready for the pregnancy to end so that we can have sex again.
- B. My husband has gained quite a bit of weight during this pregnancy.
- C. My husband seems more worried about our finances now than before the pregnancy.
- D. My husband plays his favorite music for my belly so the baby will learn to like it.
Correct Answer: A
Rationale: If the husband is overly focused on resuming sexual activity postpartum, it might indicate a lack of emotional support for the pregnant partner, warranting counseling.
The nurse who will care for a patient in labor receives a report and is told that the patient's status is as follows: 4 cm, 50%, and +1 station. What should be the nurse's interpretation of this information?
- A. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm below the ischial spines.
- B. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm above the ischial spines.
- C. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm below the ischial spines.
- D. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm above the ischial spines.
Correct Answer: C
Rationale: The correct interpretation is C because in labor progress, cervical dilation (4 cm) refers to how much the cervix has opened, effacement (50%) indicates the thinning of the cervix, and station (+1) describes the descent of the baby's head in relation to the ischial spines. Therefore, the nurse should understand that the cervix is dilated 4 cm, effaced 50%, and the baby's head is 1 cm below the ischial spines, which is indicative of progressing labor.
Choice A is incorrect because it incorrectly describes the station as being 1 cm below the ischial spines instead of above. Choice B is incorrect as it inaccurately states that the cervix is effaced to 50% rather than dilated. Choice D is incorrect because it states that the cervix is effaced 4 cm, which is not a correct representation of effacement.
A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?
- A. apply warm compresses
- B. apply cold compresses
- C. provide distraction techniques
- D. apply lanolin cream
Correct Answer: B
Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.
What is the most common site for fertilization?
- A. Lower segment of the uterus
- B. Outer third of the fallopian tube near the ovary
- C. Upper portion of the uterus
- D. Area of the fallopian tube farthest from the ovary
Correct Answer: B
Rationale: Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.
A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?
- A. Perform a vaginal exam to assess for fetal position
- B. Prepare the patient for delivery
- C. Administer an epidural block
- D. Continue to monitor contractions and fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.