Nokea
A woman in her third trimester advises the nurse that she wishes to breastfeed her baby, 'but I don’t think my nipples are right.' Upon examination, the nurse notes that the client has inverted nipples. Which of the following actions should the nurse take at this time?
- A. Advise the client that it is unlikely that she will be able to breastfeed.
- B. Refer the client to a lactation consultant for advice.
- C. Call the labor room and notify them that a client with inverted nipples will be admitted.
- D. Teach the woman exercises to exert her nipples.
Correct Answer: B
Rationale: Inverted nipples can make breastfeeding challenging, but with proper guidance from a lactation consultant, many women are able to breastfeed successfully. Exercises to exert the nipples may also be helpful, but referral to a specialist is the best initial action.
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A nurse is assessing a 26-week pregnant patient who is concerned about stretch marks. Which of the following interventions should the nurse suggest?
- A. Use over-the-counter creams and lotions to prevent stretch marks.
- B. There are no effective interventions to prevent stretch marks, but moisturizing the skin can help reduce discomfort.
- C. Take vitamin supplements to improve skin elasticity and prevent stretch marks.
- D. Stretch marks can be completely prevented by staying hydrated and exercising regularly.
Correct Answer: B
Rationale: The correct answer is B because stretch marks are primarily influenced by genetics and skin elasticity. Moisturizing the skin can help reduce discomfort associated with stretch marks but cannot prevent them entirely. A is incorrect because over-the-counter creams are not proven to prevent stretch marks. C is incorrect because while some vitamins may promote skin health, they cannot completely prevent stretch marks. D is incorrect because while staying hydrated and exercising are important for overall health, they cannot guarantee the prevention of stretch marks.
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
- A. The nurse midwife saw that the mucous plug was intact.
- B. The nurse midwife felt the baby rebound after being pushed.
- C. The nurse midwife palpated the fetal parts through the uterine wall.
- D. The nurse midwife assessed that the baby is head down.
Correct Answer: B
Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.
A nurse is caring for a pregnant patient at 32 weeks gestation who is experiencing severe leg cramps. What is the nurse's most appropriate intervention?
- A. Encourage the patient to perform gentle stretching exercises and elevate the legs.
- B. Instruct the patient to take calcium supplements to prevent cramps.
- C. Apply heat or cold packs to the affected area to reduce pain.
- D. Administer pain medications to alleviate discomfort.
Correct Answer: A
Rationale: The correct answer is A because gentle stretching exercises help relieve muscle tension and improve circulation, alleviating leg cramps. Elevating the legs can also help reduce swelling and promote blood flow. Choice B is incorrect because while calcium is essential for muscle function, it is not the primary intervention for acute leg cramps. Choice C may provide temporary relief but does not address the underlying cause of the cramps. Choice D should be avoided in pregnancy unless absolutely necessary due to potential risks to the fetus.
The nurse is caring for a pregnant patient who is 37 weeks gestation and is experiencing contractions every 10 minutes. Which of the following should the nurse assess first?
- A. The patient's vital signs and fetal heart rate
- B. The patient's cervical dilation and effacement
- C. The patient's urinary output and fluid balance
- D. The patient's emotional status and support system
Correct Answer: B
Rationale: The correct answer is B: The patient's cervical dilation and effacement. At 37 weeks gestation with contractions every 10 minutes, assessing cervical dilation and effacement is crucial to determine if the patient is in active labor. This information will guide the nurse in determining the appropriate next steps for the patient's care, such as the need for further monitoring or interventions. Assessing vital signs and fetal heart rate (Choice A) is important but not the priority in this scenario. Urinary output and fluid balance (Choice C) are important considerations but not the immediate priority. Emotional status and support system (Choice D) are also important but not the first assessment to be made in this situation.
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
- A. The nurse midwife saw that the mucous plug was intact.
- B. The nurse midwife felt the baby rebound after being pushed.
- C. The nurse midwife palpated the fetal parts through the uterine wall.
- D. The nurse midwife assessed that the baby is head down.
Correct Answer: B
Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.