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During a vaginal birth, a birthing person experienced a second-degree perineal laceration. What is a characteristic of a second-degree laceration?
- A. It involves only the vaginal mucosa.
- B. It extends through the vaginal and perineal muscles.
- C. It is the least severe type of laceration.
- D. It does not require suturing.
Correct Answer: B
Rationale: The correct answer is B because a second-degree perineal laceration extends through the vaginal mucosa and perineal muscles. First, a second-degree laceration involves more than just the vaginal mucosa, as it also affects the perineal muscles. This type of laceration is more severe than a first-degree laceration, which only involves the vaginal mucosa. Second, due to the involvement of deeper structures like the perineal muscles, suturing is typically required to promote proper healing and prevent complications. Therefore, choice B is correct. Choices A and C are incorrect because a second-degree laceration involves more than just the vaginal mucosa and is not the least severe type of laceration. Choice D is incorrect because suturing is usually necessary for second-degree lacerations.
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A nurse is caring for a pregnant patient who is experiencing nausea and vomiting. Which of the following should be included in the teaching plan?
- A. Eat small, frequent meals and avoid spicy or fatty foods.
- B. Drink large amounts of water to flush out toxins.
- C. Lie flat on your back to help settle your stomach.
- D. Avoid eating any food until the nausea resolves completely.
Correct Answer: A
Rationale: The correct answer is A: Eat small, frequent meals and avoid spicy or fatty foods. This is because small, frequent meals can help manage nausea by preventing the stomach from becoming too full, while avoiding spicy or fatty foods can reduce irritation and ease digestion. Option B is incorrect as excessive water intake can worsen nausea. Option C is wrong as lying flat on the back can exacerbate nausea and is not recommended during pregnancy. Option D is incorrect because skipping meals can lead to low blood sugar levels, worsening nausea. Overall, choice A aligns with evidence-based strategies for managing nausea and vomiting in pregnancy.
Which client consumed the most dairy servings in one day?
- A. Client 1
- B. Client 2
- C. Client 3
- D. Client 4
Correct Answer: B
Rationale: Client 2 consumed the highest number of dairy servings based on the provided quantities of yogurt, milk, cottage cheese, and hard cheese.
The nurse is caring for a pregnant patient who is 26 weeks gestation and has a history of gestational diabetes. Which of the following actions is most important for the nurse to monitor during this pregnancy?
- A. Blood glucose levels and fetal growth
- B. Urine protein levels and blood pressure
- C. Maternal weight gain and diet
- D. Fetal heart rate and activity patterns
Correct Answer: A
Rationale: The correct answer is A: Blood glucose levels and fetal growth. Monitoring blood glucose levels is crucial in managing gestational diabetes to prevent complications for both the mother and baby. High blood glucose levels can lead to macrosomia (excessive fetal growth). Monitoring fetal growth is important to ensure the baby is growing appropriately.
Choice B is incorrect because urine protein levels and blood pressure are typically monitored for preeclampsia, not specifically for a patient with gestational diabetes. Choice C is incorrect because while maternal weight gain and diet are important factors, monitoring blood glucose levels takes precedence in managing gestational diabetes. Choice D is incorrect because while fetal heart rate and activity patterns are important, monitoring blood glucose levels is more crucial in this scenario due to the patient's history of gestational diabetes.
A 32-year-old patient who is pregnant with her first child is inquiring about labor and delivery. Which of the following statements by the nurse is most appropriate?
- A. Labor usually lasts 12 to 24 hours for first-time mothers.
- B. Labor typically lasts 6 to 8 hours for first-time mothers.
- C. Labor for first-time mothers is usually much shorter than for those having their second child.
- D. Labor can be unpredictable, but it usually takes less than 12 hours for first-time mothers.
Correct Answer: A
Rationale: The correct answer is A: Labor usually lasts 12 to 24 hours for first-time mothers. This is the most appropriate response as it provides a realistic timeframe for labor in first-time mothers, which can vary but generally falls within this range. This information prepares the patient for a potentially lengthy labor and helps manage expectations.
Choice B is incorrect because stating that labor typically lasts 6 to 8 hours for first-time mothers is too short of a timeframe, which may lead to unrealistic expectations.
Choice C is incorrect because it inaccurately suggests that labor for first-time mothers is usually much shorter than for those having their second child, which is not necessarily true.
Choice D is incorrect because while labor can be unpredictable, stating that it usually takes less than 12 hours for first-time mothers is not accurate, as labor duration can vary greatly among individuals.
A patient who is 38 weeks pregnant presents to the labor and delivery unit. Upon vaginal examination, it is determined the fetus is engaged. What is the correct interpretation by the nurse?
- A. The cervix is completely effaced.
- B. The lie is longitudinal.
- C. The fetal head is flexed.
- D. The biparietal diameter of the fetal head is at the level of the ischial spines.
Correct Answer: D
Rationale: The correct interpretation by the nurse is D: The biparietal diameter of the fetal head is at the level of the ischial spines. At 38 weeks, engagement indicates the fetal head has descended into the pelvis and reached the level of the ischial spines. This is a crucial landmark in labor progress, indicating descent and readiness for birth. Choices A, B, and C are incorrect. Choice A refers to cervical effacement, which is not related to engagement. Choice B refers to fetal lie, which describes the relationship of the fetal spine to the maternal spine. Choice C refers to fetal head flexion, which is important for the mechanism of labor but not specifically related to engagement.