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A nurse is educating a postpartum person about perineal care. What is the most important teaching point?
- A. encourage the person to use a peri-bottle
- B. educate the person on wound care
- C. instruct the person to perform Kegel exercises
- D. advise the person to avoid using tampons
Correct Answer: A
Rationale: The correct answer is A: encourage the person to use a peri-bottle. This is crucial for maintaining perineal hygiene and preventing infection after childbirth. Using a peri-bottle helps keep the perineal area clean without causing irritation.
Explanation of why the other choices are incorrect:
B: Educating on wound care is important but not the most critical teaching point as keeping the area clean with a peri-bottle is the priority.
C: Kegel exercises are beneficial for pelvic floor muscles but are not directly related to perineal care.
D: Avoiding tampons is important to prevent infection, but using a peri-bottle for hygiene is more immediate and necessary postpartum.
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A pregnant person in the first stage of labor experiences rupture of membranes. What is the nurse's priority action?
- A. Administer an epidural for pain relief.
- B. Start an IV line and administer antibiotics.
- C. Document the FHR and time and characteristics of the amniotic fluid.
- D. Prepare for immediate delivery.
Correct Answer: C
Rationale: The correct answer is C because documenting the fetal heart rate (FHR) and characteristics of amniotic fluid is crucial to assess fetal well-being and monitor for signs of distress. This information helps guide further management decisions. Administering an epidural (A) is not the priority at this stage. Starting an IV line and administering antibiotics (B) may be needed later but not the immediate priority. Preparing for immediate delivery (D) is premature without assessing the fetal status first.
The nurse is providing education to a pregnant patient who is experiencing nausea and vomiting during pregnancy. Which of the following interventions should the nurse recommend?
- A. Increase fluid intake with large amounts of water at once.
- B. Eat small, frequent meals and avoid greasy foods.
- C. Take over-the-counter anti-nausea medications without consulting a doctor.
- D. Lie flat on your back immediately after eating to prevent reflux.
Correct Answer: B
Rationale: The correct answer is B because eating small, frequent meals and avoiding greasy foods can help manage nausea and vomiting during pregnancy by preventing the stomach from becoming too full or empty. Large amounts of water at once (choice A) can worsen nausea. Taking anti-nausea medications without consulting a doctor (choice C) can be unsafe during pregnancy. Lying flat on your back after eating (choice D) can increase the risk of acid reflux.
A pregnant patient is at 32 weeks gestation and reports swelling of the feet and legs. What is the most appropriate recommendation for the nurse to make?
- A. Limit fluid intake to reduce swelling.
- B. Elevate the legs and avoid prolonged standing.
- C. Apply compression stockings to improve circulation.
- D. Rest in bed with the feet elevated at all times.
Correct Answer: B
Rationale: The correct answer is B. Elevating the legs and avoiding prolonged standing is the most appropriate recommendation for a pregnant patient experiencing swelling at 32 weeks gestation. Elevating the legs helps to reduce swelling by aiding in venous return and reducing fluid accumulation in the lower extremities. Prolonged standing can worsen swelling due to increased pressure on the veins. Limiting fluid intake (choice A) may lead to dehydration and is not recommended during pregnancy. Applying compression stockings (choice C) may help improve circulation but may not address the underlying cause of swelling. Resting in bed with feet elevated at all times (choice D) is excessive and may not be practical for the patient.
A patient who is 40 weeks pregnant and is in labor suddenly complains of a severe headache and blurry vision. What should the nurse assess for?
- A. Preeclampsia
- B. Fetal distress
- C. Uterine rupture
- D. Placenta previa
Correct Answer: A
Rationale: The correct answer is A: Preeclampsia. In this scenario, the sudden onset of severe headache and blurry vision in a pregnant woman in labor are indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and signs of organ damage. The nurse should assess for other symptoms of preeclampsia such as hypertension, proteinuria, edema, and epigastric pain. Preeclampsia can lead to eclampsia, seizures, and life-threatening complications for both the mother and the baby if not promptly managed.
Summary:
B: Fetal distress - Not the priority assessment when the mother is experiencing symptoms indicative of a serious maternal condition like preeclampsia.
C: Uterine rupture - Symptoms are not suggestive of uterine rupture, which typically presents with severe abdominal pain, vaginal bleeding, and signs of shock.
D: Placenta previa - Symptoms are not consistent with placenta previa, which typically
The blood of a pregnant client was initially assessed at 10 weeks’ gestation and reassessed at 38 weeks’ gestation.
- A. Rise in hematocrit from 34% to 38%.
- B. Rise in white blood cells from 5 000 cells/mm3 to 15 000 cells/mm3.
- C. Rise in potassium from 3.9 mEq/L to 5.2 mEq/L.
- D. Rise in sodium from 137 mEq/L to 150 mEq/L.
Correct Answer: B
Rationale: White blood cell count increases during pregnancy due to physiological stress and immune system changes. Hematocrit levels typically decrease due to plasma expansion, while potassium and sodium levels remain stable.