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A woman states that she frequently awakens with 'painful leg cramps' during the night. Which of the following assessments should the nurse make?
- A. Dietary evaluation.
- B. Goodell’s sign.
- C. Hegar’s sign.
- D. Posture evaluation.
Correct Answer: A
Rationale: Leg cramps during pregnancy are often related to dietary deficiencies, particularly calcium and magnesium. A dietary evaluation is the most appropriate assessment.
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A pregnant patient at 26 weeks gestation reports pain in the lower abdomen and back. What should the nurse do first?
- A. Encourage the patient to rest and monitor for changes in symptoms.
- B. Perform a pelvic exam to assess for possible cervical dilation.
- C. Administer pain medication to relieve the discomfort.
- D. Assess the patient's blood pressure and check for signs of preeclampsia.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to rest and monitor for changes in symptoms. At 26 weeks gestation, lower abdominal and back pain could indicate preterm labor. The first step is to have the patient rest to reduce uterine activity. Monitoring for changes in symptoms is crucial to assess if the pain is worsening and if there are any signs of preterm labor. Performing a pelvic exam (B) could potentially stimulate contractions and should be avoided unless absolutely necessary. Administering pain medication (C) does not address the underlying cause and could mask symptoms. Assessing blood pressure for signs of preeclampsia (D) is important but not the first priority in this scenario.
A nurse is caring for a postpartum person who is breastfeeding. What is the most important action to support successful breastfeeding?
- A. educate the person on proper latch
- B. support skin-to-skin contact
- C. promote frequent feeding
- D. educate on postpartum care
Correct Answer: B
Rationale: The correct answer is B: support skin-to-skin contact. Skin-to-skin contact immediately after birth helps regulate the baby's body temperature, promotes bonding, and enhances breastfeeding success by stimulating the baby's natural instincts to latch on and feed. This action establishes a strong foundation for successful breastfeeding.
Rationale:
1. Skin-to-skin contact promotes bonding and attachment between the parent and baby, creating a supportive environment for breastfeeding.
2. It helps regulate the baby's body temperature, ensuring they are comfortable and more willing to breastfeed effectively.
3. Skin-to-skin contact triggers the baby's natural feeding reflexes, making it easier for them to latch on properly.
4. This action fosters a positive breastfeeding experience for both the parent and baby, setting the stage for successful breastfeeding.
Summary:
- Choice A: educating on proper latch is important, but skin-to-skin contact is more crucial for establishing successful breastfeeding.
- Choice C: promoting frequent feeding is beneficial, but skin-to
A pregnant patient at 36 weeks gestation reports feeling more tired than usual. What is the nurse's priority action?
- A. Encourage the patient to get more rest and limit physical activity.
- B. Assess the patient for signs of anemia or other complications.
- C. Administer iron supplements to improve energy levels.
- D. Instruct the patient to increase caloric intake to meet energy demands.
Correct Answer: B
Rationale: The correct answer is B. Assess the patient for signs of anemia or other complications. At 36 weeks gestation, fatigue can be a sign of anemia, a common issue in pregnancy. Anemia can lead to complications for both the mother and the baby, so assessing for this is crucial. Encouraging rest (choice A) may help with fatigue temporarily but does not address the underlying cause. Administering iron supplements (choice C) without assessing first can be harmful if anemia is not the issue. Instructing the patient to increase caloric intake (choice D) is not the priority as it does not address the potential medical issue causing the fatigue.
The nurse’s role in diagnostic testing is to provide which of the following?
- A. Advice to the couple
- B. Information about the tests
- C. Reassurance about fetal safety
- D. Assistance with decision making
Correct Answer: B
Rationale: The nurse's role is to provide all necessary information regarding a procedure to enable the couple to make an informed decision.
A nurse is caring for a postpartum person who is at risk for uterine atony. What is the priority intervention to prevent uterine atony?
- A. administer uterotonic medication
- B. administer an analgesic
- C. perform uterine massage
- D. administer IV fluids
Correct Answer: B
Rationale: The correct answer is B: administer an analgesic. This is the priority intervention because pain management helps the person relax, which reduces stress on the uterus and promotes effective contraction to prevent uterine atony. Administering uterotonic medication (choice A) may help contract the uterus but addressing pain first is crucial. Performing uterine massage (choice C) can assist in contracting the uterus but is not the priority intervention. Administering IV fluids (choice D) is important for hydration but does not directly address preventing uterine atony.