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During the first stage of labor, what is the primary goal of nursing care in the early phase?
- A. Administer pain medication.
- B. Monitor fetal heart rate continuously.
- C. Promote relaxation and provide comfort measures.
- D. Prepare for imminent delivery.
Correct Answer: C
Rationale: The correct answer is C because during the early phase of labor, the primary goal of nursing care is to promote relaxation and provide comfort measures to help the mother cope with contractions and manage pain. This helps create a calm and supportive environment, enhancing the progress of labor. Administering pain medication (A) may be necessary later, not necessarily in the early phase. Monitoring fetal heart rate continuously (B) is important but not the primary goal in the early phase. Preparing for imminent delivery (D) is premature in the early phase, as labor can be lengthy.
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A nurse is caring for a pregnant woman who is at 40 weeks gestation and is experiencing a prolonged labor. Which of the following interventions is most appropriate to promote labor progression?
- A. Administer a sedative to help the patient rest.
- B. Encourage the patient to walk or change positions.
- C. Administer oxytocin to strengthen contractions.
- D. Perform a cesarean section immediately.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to walk or change positions. This intervention helps to promote gravity-assisted descent of the fetus, aiding in cervical dilation and labor progression. Walking and changing positions can also help alleviate pain and discomfort, facilitate optimal fetal positioning, and prevent maternal exhaustion. Administering a sedative (A) can potentially slow down labor progress. Administering oxytocin (C) may be indicated in certain situations, but it is not the most appropriate initial intervention for promoting labor progression in this case. Performing a cesarean section (D) is not warranted unless there are specific medical indications for it, as it is a major surgical procedure with potential risks.
A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention for sore nipples?
- A. apply lanolin cream
- B. administer IV fluids
- C. perform uterine massage
- D. apply cold compress
Correct Answer: A
Rationale: The correct answer is A: apply lanolin cream. Lanolin cream helps soothe and moisturize sore nipples, providing relief during breastfeeding. It is safe for both the mother and the baby. Applying lanolin cream after each feeding can prevent further irritation and promote healing.
Incorrect choices:
B: Administering IV fluids is not indicated for sore nipples.
C: Performing uterine massage is unrelated to treating sore nipples.
D: Applying cold compress may provide temporary relief but does not address the underlying issue of sore nipples.
Which food can a lactose-intolerant pregnant woman consume for calcium?
- A. Turnip greens
- B. Green beans
- C. Cantaloupe
- D. Nectarines
Correct Answer: A
Rationale: Turnip greens are rich in calcium, making them a suitable alternative for lactose-intolerant individuals.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
- A. Magnesium sulfate
- B. Prostaglandin suppository
- C. RhoGAM if the patient is Rh-negative
- D. Betamethasone
Correct Answer: C
Rationale: Rh-negative women undergoing CVS require RhoGAM to prevent Rh sensitization.
A nurse is assessing a laboring person for signs of fetal distress. What is the most common sign of fetal distress?
- A. increase oxygen flow
- B. tachycardia
- C. bradycardia
- D. irregular fetal heart rate
Correct Answer: B
Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.