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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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The nurse is assessing a 38-week pregnant woman who is experiencing severe abdominal pain and has not felt her baby move for several hours. What is the most appropriate action for the nurse to take?
- A. Encourage the patient to drink water and rest.
- B. Notify the healthcare provider immediately.
- C. Ask the patient to lie on her left side and monitor fetal movements.
- D. Reassure the patient that this is common at the end of pregnancy.
Correct Answer: B
Rationale: The correct answer is B: Notify the healthcare provider immediately. This is the most appropriate action because the pregnant woman is experiencing severe abdominal pain and has not felt her baby move for several hours, which could indicate a potential emergency situation such as placental abruption or fetal distress. Prompt notification of the healthcare provider is crucial for timely evaluation and management to ensure the well-being of both the mother and the baby.
Choice A is incorrect because simply encouraging the patient to drink water and rest may delay necessary medical intervention. Choice C is incorrect as monitoring fetal movements without immediate healthcare provider notification may lead to a critical delay in assessment and treatment. Choice D is incorrect as reassuring the patient without further evaluation could overlook a serious issue.
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 nurse is assessing a postpartum person's pain level following a cesarean section. What is the most appropriate intervention for pain management?
- A. administer IV fluids
- B. administer narcotics
- C. perform gentle uterine massage
- D. perform gentle fundal massage
Correct Answer: C
Rationale: The correct answer is C: perform gentle uterine massage. This intervention is appropriate as it helps to stimulate uterine contractions, which can reduce postpartum bleeding and pain. Uterine massage also helps to promote involution of the uterus, aiding in the recovery process. Administering IV fluids (A) may be necessary but does not directly address pain management. Administering narcotics (B) may provide pain relief but should be used judiciously due to potential side effects. Performing gentle fundal massage (D) is not recommended as it may cause discomfort and is not as effective in managing post-cesarean pain compared to uterine massage.
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.
A nurse is caring for a postpartum person who is at risk for infection. What is the most important nursing action to reduce the risk of infection?
- A. provide perineal care and hygiene
- B. ensure proper hand hygiene
- C. offer antibiotics as needed
- D. ensure proper infection control practices
Correct Answer: C
Rationale: The correct answer is C: offer antibiotics as needed. In postpartum individuals at high risk for infection, antibiotics may be necessary to prevent or treat infections. Antibiotics target specific pathogens, reducing the risk of infection. Proper hand hygiene (B) and infection control practices (D) are important but do not directly address the underlying risk of infection. Providing perineal care and hygiene (A) is essential for overall hygiene but may not be sufficient in preventing infections in high-risk individuals. Antibiotics, when prescribed judiciously and appropriately, can be crucial in reducing the risk of infection and promoting recovery.