A nurse is preparing a postpartum person for discharge. What is the most important aspect of discharge teaching for a person who has had a cesarean section?
- A. ensure proper incision care
- B. teach about signs of infection
- C. provide skin-to-skin contact
- D. assess for bleeding
Correct Answer: B
Rationale: The correct answer is B: teach about signs of infection. This is the most important aspect of discharge teaching for a person who has had a cesarean section because infection is a common complication post-surgery. By educating the person on signs of infection such as fever, increased pain, redness, or discharge from the incision site, they can promptly seek medical attention if needed. Ensuring proper incision care (choice A) is important but preventing infection through early detection is crucial. Providing skin-to-skin contact (choice C) is beneficial for bonding but not directly related to post-cesarean care. Assessing for bleeding (choice D) is important but typically done in a healthcare setting post-surgery.
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When analyzing the need for health teaching of a prenatal multigravida, the nurse should ask which of the following questions?
- A. What are the ages of your children?
- B. What is your marital status?
- C. Do you ever drink alcohol?
- D. Do you have any allergies?
Correct Answer: C
Rationale: Asking about alcohol consumption is directly related to health teaching needs, as it can impact fetal development. The other questions, while important, are not directly related to health teaching.
The nurse is counseling a female patient about alcohol use during pregnancy. Which statement by the patient demonstrates successful patient teaching?
- A. I will limit my drinking to just one alcoholic beverage per day.
- B. It's best for my baby if I avoid drinking during pregnancy.
- C. An occasional drink on special occasions is okay.
- D. Drinking alcohol is only acceptable in the first trimester.
Correct Answer: B
Rationale: The correct answer is B because complete abstinence from alcohol is the safest option during pregnancy to prevent any potential harm to the fetus. This statement shows understanding of the importance of avoiding alcohol for the well-being of the baby. Choice A suggests drinking daily, which can still pose risks. Choice C implies occasional drinking is acceptable, which can still be harmful. Choice D is incorrect because alcohol should be avoided throughout pregnancy, not just in the first trimester.
A nurse is monitoring a laboring person's vital signs during the first stage of labor. Which vital sign change is most likely to indicate the need for further evaluation?
- A. decrease in heart rate
- B. increase in blood pressure
- C. increase in pulse rate
- D. no change in vital signs
Correct Answer: B
Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby.
A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions.
C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high.
D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.
A pregnant patient at 30 weeks gestation reports experiencing dizziness and faintness when standing up. What is the most likely cause of these symptoms?
- A. Low blood sugar levels due to gestational diabetes.
- B. Dehydration and electrolyte imbalance.
- C. Decreased blood pressure due to pregnancy-related changes.
- D. Anemia and low iron levels.
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure due to pregnancy-related changes. During pregnancy, blood vessels dilate and the growing uterus can compress the vena cava, leading to decreased blood return to the heart when standing up, causing dizziness and faintness. This condition is known as orthostatic hypotension, common in the third trimester. Low blood sugar levels (choice A) and dehydration/electrolyte imbalance (choice B) can also cause dizziness but are less likely in this scenario. Anemia and low iron levels (choice D) can lead to fatigue and weakness but are less likely to cause dizziness and faintness when standing up in this context.
What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?
- A. Positive
- B. Negative
- C. Reactive
- D. Nonreactive
Correct Answer: C
Rationale: A nonstress test is considered reactive when there are at least two accelerations of 15 BPM or more in a 20-minute period, indicating fetal well-being.