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A nurse is preparing a laboring person for an epidural. What is the most important nursing intervention before the procedure?
- A. Ensure informed consent is signed
- B. Administer IV fluids
- C. Monitor maternal vital signs
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Ensure informed consent is signed. Before any procedure, it is crucial to obtain informed consent to ensure the individual understands the risks, benefits, and alternatives. This protects their autonomy and ensures they are making an informed decision. Administering IV fluids (B) is important but not as critical as obtaining consent. Monitoring vital signs (C) is essential but not the most important step before the procedure. Administering pain relief (D) should only be done after ensuring informed consent and assessing the individual's pain level.
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A pregnant woman states, “My husband hopes I will give him a boy because we have three girls.” What will the nurse explain to this woman?
- A. The sex chromosome of the fertilized ovum determines the gender of the child.
- B. When the sperm and ovum are united, there is a 75% chance the child will be a girl.
- C. When the pH of the female reproductive tract is acidic, the child will be a girl.
- D. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.
Correct Answer: D
Rationale: When a Y-bearing sperm fertilizes an ovum, a male child is produced.
Which food is best for constipation relief?
- A. Pasta
- B. Rice
- C. Yogurt
- D. Celery
Correct Answer: D
Rationale: Celery is high in fiber and water, making it an effective choice for relieving constipation.
A pregnant patient at 26 weeks gestation reports nausea and vomiting. What is the nurse's priority action?
- A. Administer anti-nausea medications as prescribed.
- B. Instruct the patient to eat larger meals less frequently.
- C. Encourage the patient to eat smaller, more frequent meals and avoid greasy foods.
- D. Encourage the patient to rest and avoid physical activity.
Correct Answer: C
Rationale: The correct answer is C because nausea and vomiting are common during pregnancy and can be alleviated by eating smaller, more frequent meals and avoiding greasy foods. This strategy helps maintain stable blood sugar levels and reduces gastric distress. Administering anti-nausea medications (A) should only be considered if conservative measures fail. Instructing the patient to eat larger meals less frequently (B) may worsen symptoms. Encouraging rest and avoiding physical activity (D) may be beneficial but addressing dietary factors is the priority in this case.
How long should clamping of the cord be delayed in an uncomplicated delivery to increase the newborn's hemoglobin levels and improve circulation?
- A. 30–60 seconds
- B. 15–30 seconds
- C. 30 seconds
- D. Delayed cord clamping is not recommended.
Correct Answer: A
Rationale: The correct answer is A (30-60 seconds) for delayed cord clamping in an uncomplicated delivery. Delaying cord clamping for 30-60 seconds allows more blood to flow from the placenta to the baby, increasing the baby's hemoglobin levels and improving circulation. This extra blood transfer can provide the baby with essential nutrients and oxygen, reducing the risk of anemia and improving overall health outcomes.
Choice B (15-30 seconds) may not provide enough time for sufficient blood transfer compared to the optimal window of 30-60 seconds.
Choice C (30 seconds) is within the recommended range, but 30-60 seconds is considered more beneficial for maximizing blood flow to the newborn.
Choice D (Delayed cord clamping is not recommended) is incorrect as delayed cord clamping has been shown to have various benefits for newborns when done in uncomplicated deliveries.
A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse’s most appropriate response?
- A. The test results are within normal limits.
- B. Immediate birth by cesarean birth is being considered.
- C. Further testing will be performed to determine the meaning of this score.
- D. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.
Correct Answer: A
Rationale: A score of 8-10 is within the normal range for a biophysical profile, indicating no immediate concerns for the fetus.