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A nurse is monitoring a postpartum person for signs of infection. Which finding would be most concerning in the first 24 hours after delivery?
- A. fever
- B. foul-smelling lochia
- C. increased blood pressure
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: fever. A fever in the first 24 hours after delivery is most concerning as it may indicate an infection, such as endometritis, which can lead to serious complications if not promptly treated. Postpartum fever is often the earliest sign of infection due to retained products of conception or ascending genital tract infection. Monitoring for fever is crucial as it can help prevent sepsis. Foul-smelling lochia (choice B) may suggest infection but is not as immediate a concern as fever. Increased blood pressure (choice C) and heart rate (choice D) may be normal physiological responses to delivery and are not specific indicators of infection in the immediate postpartum period.
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A nurse is caring for a laboring person who is experiencing late decelerations in fetal heart rate. What is the priority nursing intervention?
- A. place the person on their left side
- B. apply oxygen via mask
- C. administer pain medication
- D. perform a vaginal examination
Correct Answer: A
Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.
The nurse is caring for a pregnant patient who is 36 weeks gestation and is concerned about the upcoming delivery. Which of the following statements by the nurse is most appropriate?
- A. Labor will likely be quick and easy, especially since this is your first pregnancy.
- B. Labor can be unpredictable, and each birth is different.
- C. You will probably need a cesarean section since you are at full term.
- D. You may not feel any pain during labor because of modern pain relief options.
Correct Answer: B
Rationale: The correct answer is B: "Labor can be unpredictable, and each birth is different." This response acknowledges the variability and individuality of labor experiences, providing reassurance to the patient. Labor outcomes depend on various factors such as maternal health, baby's position, and other unforeseen circumstances.
Explanation:
1. A (Labor will likely be quick and easy, especially since this is your first pregnancy): This statement is incorrect because the duration and ease of labor are not solely determined by the patient's parity (number of pregnancies). Each labor is unique and may vary in length and intensity regardless of previous pregnancies.
2. C (You will probably need a cesarean section since you are at full term): This statement is incorrect as the majority of pregnant women deliver vaginally at full term. Cesarean section is not a predetermined outcome solely based on gestational age.
3. D (You may not feel any pain during labor because of modern pain relief options): This statement is incorrect because pain
A pregnant patient at 28 weeks gestation is experiencing severe swelling in her hands and feet. Which of the following actions should the nurse take first?
- A. Assess the patient's blood pressure and check for signs of preeclampsia.
- B. Encourage the patient to elevate her legs and rest.
- C. Monitor the patient's urine output and report any changes.
- D. Schedule an ultrasound to assess fetal growth and amniotic fluid levels.
Correct Answer: A
Rationale: The correct action to take first is to assess the patient's blood pressure and check for signs of preeclampsia (Answer A). Preeclampsia is a serious condition characterized by high blood pressure and signs of organ dysfunction. In this scenario, the patient's severe swelling could be indicative of preeclampsia, which poses a risk to both the mother and the fetus. By assessing blood pressure and looking for other signs of preeclampsia, the nurse can determine the urgency of the situation and take appropriate actions to manage the condition.
Encouraging leg elevation and rest (Answer B) may help alleviate some symptoms but does not address the underlying cause of the swelling. Monitoring urine output (Answer C) is important for overall assessment but does not address the immediate concern of potential preeclampsia. Scheduling an ultrasound (Answer D) is not the priority in this situation as it does not provide information about the patient's current condition and does not address the
A pregnant patient at 32 weeks gestation reports increased pressure in the pelvic area and mild cramping. What should the nurse assess first?
- A. The fetal heart rate and signs of labor.
- B. The patient's blood pressure and urine for protein.
- C. The presence of vaginal discharge or bleeding.
- D. The patient's dietary intake and hydration status.
Correct Answer: A
Rationale: The correct answer is A: The fetal heart rate and signs of labor. At 32 weeks gestation, any pelvic pressure and cramping could be indicative of preterm labor, which is a critical concern. Assessing the fetal heart rate can help determine fetal well-being and signs of distress. Monitoring for signs of labor such as contractions, cervical changes, and rupture of membranes is essential for timely intervention.
Choice B: Assessing blood pressure and urine for protein is important in monitoring for preeclampsia, but it is not the priority in this case where signs of preterm labor are reported.
Choice C: Vaginal discharge or bleeding could indicate various conditions, but in this scenario, the focus should be on ruling out preterm labor first.
Choice D: Dietary intake and hydration status are important aspects of prenatal care, but they are not the priority when assessing a pregnant patient reporting pelvic pressure and cramping at 32 weeks gestation.
A pregnant patient is asking about the risks of smoking during pregnancy. Which of the following is the most appropriate response by the nurse?
- A. Smoking during pregnancy is safe if you don't have other complications.
- B. Smoking increases the risk of premature birth, low birth weight, and developmental delays.
- C. It's okay to smoke in moderation during pregnancy as long as you quit before delivery.
- D. Smoking only affects the mother, not the baby.
Correct Answer: B
Rationale: The correct answer is B because smoking during pregnancy significantly increases the risk of adverse outcomes such as premature birth, low birth weight, and developmental delays. Nicotine and other harmful chemicals in cigarettes can restrict oxygen and nutrients to the baby, leading to these complications. Choice A is incorrect as smoking is never safe during pregnancy. Choice C is incorrect as any amount of smoking during pregnancy is harmful. Choice D is incorrect as smoking affects both the mother and the baby due to the harmful substances passing through the placenta.