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A nurse is educating a pregnant patient about safe sleep practices for the infant. Which of the following statements by the patient indicates the need for further teaching?
- A. I will always place my baby on their back to sleep.
- B. I will place my baby in the same bed with me to make sure they are safe.
- C. I will keep soft bedding out of my baby's crib.
- D. I will encourage tummy time when my baby is awake.
Correct Answer: B
Rationale: The correct answer is B because placing the baby in the same bed increases the risk of suffocation, Sudden Infant Death Syndrome (SIDS), and other sleep-related accidents. Co-sleeping is not recommended due to the potential hazards. Choices A, C, and D are safe sleep practices. Placing the baby on their back reduces the risk of SIDS, keeping soft bedding out of the crib prevents suffocation, and tummy time is beneficial for the baby's development when they are awake.
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A nurse is caring for a pregnant patient who is at 36 weeks gestation and reports that her baby has not moved as much as usual. What should the nurse instruct the patient to do first?
- A. Lie on her left side and drink a cold beverage to stimulate movement.
- B. Rest for a few hours and count fetal movements.
- C. Call the healthcare provider immediately to report the lack of movement.
- D. Monitor fetal movement over the next 24 hours and report if the pattern continues.
Correct Answer: A
Rationale: The correct answer is A: Lie on her left side and drink a cold beverage to stimulate movement. This is because changing positions can encourage fetal movement due to the change in gravity and blood flow. Additionally, the cold beverage may stimulate the baby to move. Option B suggests resting without actively trying to stimulate movement, which may delay necessary action. Option C advises immediate contact with the healthcare provider, which could be an overreaction at this stage. Option D delays action and may not address the immediate concern of decreased fetal movement.
The nurse is caring for a pregnant patient who is concerned about preterm labor. Which of the following symptoms should the nurse instruct the patient to report immediately?
- A. Mild back pain and cramping
- B. Feeling of pelvic pressure
- C. Leaking of clear fluid from the vagina
- D. Increased fatigue during the day
Correct Answer: C
Rationale: The correct answer is C: Leaking of clear fluid from the vagina. This symptom could indicate premature rupture of membranes, which is a serious concern in preterm labor. Prompt reporting is crucial to prevent complications. A: Mild back pain and cramping are common in pregnancy and may not necessarily indicate preterm labor. B: Feeling of pelvic pressure can be normal in the third trimester. D: Increased fatigue is common in pregnancy and not a direct sign of preterm labor.
A nurse is caring for a postpartum person who is at risk for thrombophlebitis. What is the most important intervention to reduce this risk?
- A. administer anticoagulants
- B. apply compression stockings
- C. use a footstool
- D. monitor for signs of DVT
Correct Answer: A
Rationale: The correct answer is A: administer anticoagulants. Anticoagulants help prevent blood clots, reducing the risk of thrombophlebitis. Administering anticoagulants is the most effective intervention for someone at risk. Applying compression stockings (B) can help with circulation but may not be sufficient for someone at high risk. Using a footstool (C) can promote circulation but is not as direct as anticoagulants. Monitoring for signs of DVT (D) is important but not as proactive as administering anticoagulants for prevention.
The nurse is educating a pregnant patient about the importance of taking prenatal vitamins. Which of the following statements by the patient indicates effective teaching?
- A. I should take prenatal vitamins only during the first trimester.
- B. I should take prenatal vitamins throughout the pregnancy to ensure my baby gets the nutrients it needs.
- C. I should stop taking prenatal vitamins after the baby is born.
- D. I can get all the necessary nutrients from my diet without taking prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because taking prenatal vitamins throughout pregnancy ensures the baby receives essential nutrients for growth and development. Prenatal vitamins contain key nutrients like folic acid, iron, and calcium crucial for the baby's health. Choice A is incorrect because prenatal vitamins are recommended throughout pregnancy, not just the first trimester. Choice C is incorrect as prenatal vitamins may be needed postpartum if breastfeeding. Choice D is incorrect as prenatal vitamins provide additional nutrients that may not be obtained solely from diet.
A patient who is 38 weeks pregnant presents to the labor and delivery unit. Upon vaginal examination, it is determined the fetus is engaged. What is the correct interpretation by the nurse?
- A. The cervix is completely effaced.
- B. The lie is longitudinal.
- C. The fetal head is flexed.
- D. The biparietal diameter of the fetal head is at the level of the ischial spines.
Correct Answer: D
Rationale: The correct interpretation by the nurse is D: The biparietal diameter of the fetal head is at the level of the ischial spines. At 38 weeks, engagement indicates the fetal head has descended into the pelvis and reached the level of the ischial spines. This is a crucial landmark in labor progress, indicating descent and readiness for birth. Choices A, B, and C are incorrect. Choice A refers to cervical effacement, which is not related to engagement. Choice B refers to fetal lie, which describes the relationship of the fetal spine to the maternal spine. Choice C refers to fetal head flexion, which is important for the mechanism of labor but not specifically related to engagement.