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A nurse is educating a birthing person about the signs and symptoms of postpartum hemorrhage. Which of the following is an early sign of postpartum hemorrhage?
- A. bright red bleeding
- B. increased blood pressure
- C. severe abdominal pain
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: bright red bleeding. This is an early sign of postpartum hemorrhage because it indicates active bleeding from the uterus. Bright red blood suggests fresh bleeding, which is more concerning than darker blood. Increased blood pressure (B) is not typically associated with postpartum hemorrhage. Severe abdominal pain (C) is more indicative of other complications like uterine rupture. Increased heart rate (D) can be a sign of postpartum hemorrhage, but bright red bleeding is a more specific early indicator.
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A patient in labor is receiving Pitocin to augment contractions. The fetal heart rate shows late decelerations. What is the most appropriate intervention?
- A. Stop the Pitocin infusion
- B. Administer oxygen to the mother
- C. Change the patient's position
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because it addresses the potential causes of late decelerations comprehensively. Stopping Pitocin helps to eliminate uteroplacental insufficiency, administering oxygen improves fetal oxygenation, and changing the patient's position can alleviate pressure on the umbilical cord. Each intervention targets a different aspect contributing to late decelerations, making it crucial to implement all of them to optimize fetal well-being.
The nurse is caring for a patient who is in labor and being externally monitored. What should the nurse do after noting early decelerations of the FHR?
- A. Anticipate a cesarean birth
- B. Turn the patient onto the left side
- C. Continue to monitor the patient
- D. Notify the physician or nurse midwife immediately
Correct Answer: C
Rationale: The correct answer is C: Continue to monitor the patient. Early decelerations are benign and occur due to head compression during contractions. They are a normal response to fetal head compression and do not require any intervention as they are self-limiting. Continuing to monitor the patient allows the nurse to observe the pattern of decelerations and ensure they remain early and resolve on their own. Anticipating a cesarean birth (choice A) is unnecessary as early decelerations do not indicate fetal distress. Turning the patient onto the left side (choice B) is typically done for late decelerations, not early decelerations. Notifying the physician or nurse midwife immediately (choice D) is not necessary for early decelerations as they are expected and do not require immediate intervention.
During the third stage of labor, the nurse notes excessive bleeding. What should the nurse assess first?
- A. uterine tone
- B. placental separation
- C. vaginal bleeding
- D. cervical dilation
Correct Answer: A
Rationale: During the third stage of labor, the correct answer is A: uterine tone. This is because assessing uterine tone is crucial in determining if the uterus is contracting effectively to control bleeding. If the uterus is not firm (boggy), it can lead to postpartum hemorrhage. Placental separation (B) occurs during the third stage, but assessing uterine tone takes precedence. Vaginal bleeding (C) is a symptom of potential postpartum hemorrhage, which can be caused by poor uterine tone. Cervical dilation (D) is not a priority in this situation as the focus should be on controlling bleeding.
A nurse is caring for a pregnant patient at 34 weeks gestation who has been diagnosed with gestational hypertension. What is the nurse's priority intervention?
- A. Encourage the patient to rest and increase fluid intake.
- B. Monitor the patient's blood pressure regularly and assess for signs of preeclampsia.
- C. Administer antihypertensive medications as prescribed.
- D. Instruct the patient to lie on her back to relieve pressure on the uterus.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure regularly and assess for signs of preeclampsia. At 34 weeks gestation with gestational hypertension, monitoring blood pressure and assessing for signs of preeclampsia are crucial to detect any worsening condition. Preeclampsia is a serious complication of gestational hypertension that can lead to adverse outcomes for both the mother and fetus. Regular monitoring allows for timely intervention if necessary.
Choice A is incorrect because simply encouraging rest and increased fluid intake may not address the potential severity of gestational hypertension and preeclampsia.
Choice C is incorrect because administering antihypertensive medications without proper monitoring and assessment can be harmful to the patient and fetus.
Choice D is incorrect because lying on her back can actually worsen the patient's condition by decreasing blood flow to the uterus.
A pregnant patient is at 32 weeks gestation and complains of shortness of breath, swelling of the hands, and increased weight gain. What is the nurse's priority action?
- A. Administer oxygen and prepare the patient for a cesarean section.
- B. Assess the patient's blood pressure and check for protein in the urine.
- C. Encourage the patient to rest and elevate the legs.
- D. Instruct the patient to drink plenty of fluids to reduce swelling.
Correct Answer: B
Rationale: The correct answer is B. At 32 weeks gestation, the patient's symptoms suggest possible preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Assessing blood pressure and checking for proteinuria are crucial for diagnosing and managing preeclampsia. Administering oxygen or preparing for a cesarean section is not the priority without proper assessment. Encouraging rest and elevation of legs may help with swelling, but addressing the potential preeclampsia is more urgent. Instructing the patient to drink fluids is not the priority as it does not address the underlying issue of preeclampsia.