Nokea
A nurse is preparing a laboring person for a cesarean birth. What is the most important intervention before the procedure?
- A. administer preoperative medication
- B. monitor vital signs
- C. ensure proper incision care
- D. perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A because administering preoperative medication is crucial to ensure the patient's comfort and safety during the cesarean birth. Preoperative medications help reduce anxiety, prevent infection, and manage pain. Monitoring vital signs (choice B) is important but not the most critical intervention before the procedure. Ensuring proper incision care (choice C) is postoperative, not preoperative. Performing a vaginal exam (choice D) is unnecessary and potentially harmful before a cesarean birth.
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What is the priority nursing action when a postpartum person experiences a boggy uterus after delivery?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. administer an analgesic
- D. administer pain medication
Correct Answer: B
Rationale: The correct answer is B: administer a uterotonic medication. This is the priority nursing action because a boggy uterus indicates uterine atony, which can lead to postpartum hemorrhage. Uterotonic medications help the uterus contract and reduce bleeding. Performing fundal massage (A) can be done after administering the medication to aid in uterine contraction. Administering an analgesic (C) or pain medication (D) is not the priority as the main concern is preventing excessive bleeding.
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 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 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.
A nurse is educating a pregnant patient at 32 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is recommended for pregnant patients at 32 weeks gestation. This type of activity helps maintain health without putting excessive strain on the body. Strenuous exercises (Choice A) may increase the risk of injury or complications during pregnancy. Avoiding all physical activity (Choice C) can lead to decreased muscle tone and potential complications. High-impact exercises (Choice D) can be too harsh on the joints and bones during pregnancy. Therefore, moderate exercise is the safest and most beneficial option for pregnant patients at this stage.