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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Which of the following is the most accurate description of fetal station during labor?
- A. The distance from the cervix to the fetal head
- B. The level of the presenting part in relation to the ischial spines
- C. The degree of fetal flexion during contractions
- D. The amount of cervical dilation during labor
Correct Answer: B
Rationale: The correct answer is B: The level of the presenting part in relation to the ischial spines. Fetal station refers to the position of the baby's head in the mother's pelvis during labor. It is measured in centimeters above or below the ischial spines. This measurement helps determine the progress of labor and the descent of the baby through the birth canal. Choices A, C, and D do not accurately describe fetal station and are therefore incorrect. Choice A refers to the cervical length, choice C refers to fetal position, and choice D refers to cervical dilation, which are not related to fetal station.
A patient in labor is requesting pain relief. What is the most appropriate intervention for a patient in the latent phase of labor?
- A. Administer an epidural block
- B. Provide non-pharmacological pain relief methods
- C. Administer narcotic analgesics
- D. Encourage the patient to push with each contraction
Correct Answer: B
Rationale: The correct answer is B: Provide non-pharmacological pain relief methods. In the latent phase of labor, the cervix is dilated up to 6 cm and the contractions are typically mild to moderate. Non-pharmacological methods like massage, breathing techniques, warm showers, and position changes are most appropriate as they help the patient relax and cope with the pain without interfering with the progress of labor. Administering an epidural block (A) is not recommended in the latent phase as it can slow down labor. Administering narcotic analgesics (C) can affect the baby and may not provide adequate pain relief. Encouraging the patient to push (D) is not appropriate in the latent phase as it can lead to exhaustion and may not be effective until the cervix is fully dilated.
Which of the following interventions is most appropriate for a postpartum person who has difficulty initiating breastfeeding?
- A. assist with hand expression
- B. administer pain relief
- C. offer additional support and education
- D. administer a breast pump
Correct Answer: B
Rationale: The correct answer is B: administer pain relief. Pain can be a common barrier to initiating breastfeeding. By providing pain relief, the postpartum person may feel more comfortable and be better able to initiate breastfeeding. Hand expression (A) may not address the underlying issue of pain. Offering additional support and education (C) may be beneficial but addressing pain is more urgent. Administering a breast pump (D) is not necessary at this stage unless there are specific indications.
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 pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
- A. Instruct the patient to avoid standing for long periods.
- B. Encourage the patient to increase sodium intake.
- C. Recommend that the patient take frequent naps during the day.
- D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.
A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.