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A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
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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.
Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
- A. Biophysical profile
- B. Multiple-marker screening
- C. Lecithin-to-sphingomyelin ratio
- D. Blood type and crossmatch of maternal and fetal serum
Correct Answer: B
Rationale: Multiple-marker screening analyzes maternal serum for abnormal levels of AFP, hCG, inhibin A, and estriol to detect chromosomal defects.
A postpartum person is breastfeeding her newborn. What is the most appropriate action if the person is experiencing nipple pain?
- A. apply lanolin cream
- B. administer pain relief
- C. monitor the baby's latch
- D. provide distraction techniques
Correct Answer: B
Rationale: The correct answer is B: administer pain relief. Nipple pain during breastfeeding can be caused by various factors such as improper latch, engorgement, or infection. Administering pain relief can help alleviate the discomfort temporarily while addressing the root cause. Applying lanolin cream (choice A) may help with moisturizing the nipples but won't address the underlying issue causing the pain. Monitoring the baby's latch (choice C) is important for long-term prevention but may not provide immediate relief. Providing distraction techniques (choice D) is not addressing the physical pain and may not be effective in resolving the issue. Administering pain relief is the most appropriate immediate action to help the postpartum person manage the discomfort while addressing the cause of the pain.
The nurse who will care for a patient in labor receives a report and is told that the patient's status is as follows: 4 cm, 50%, and +1 station. What should be the nurse's interpretation of this information?
- A. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm below the ischial spines.
- B. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm above the ischial spines.
- C. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm below the ischial spines.
- D. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm above the ischial spines.
Correct Answer: C
Rationale: The correct interpretation is C because in labor progress, cervical dilation (4 cm) refers to how much the cervix has opened, effacement (50%) indicates the thinning of the cervix, and station (+1) describes the descent of the baby's head in relation to the ischial spines. Therefore, the nurse should understand that the cervix is dilated 4 cm, effaced 50%, and the baby's head is 1 cm below the ischial spines, which is indicative of progressing labor.
Choice A is incorrect because it incorrectly describes the station as being 1 cm below the ischial spines instead of above. Choice B is incorrect as it inaccurately states that the cervix is effaced to 50% rather than dilated. Choice D is incorrect because it states that the cervix is effaced 4 cm, which is not a correct representation of effacement.
A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?
- A. verify the person's immunization history
- B. obtain informed consent
- C. check for signs of an allergic reaction
- D. ensure proper positioning for the vaccine
Correct Answer: D
Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.