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During the fourth stage of labor, a nurse assesses the perineum of a birthing person who had a vaginal birth. What is the primary purpose of this assessment?
- A. to evaluate the birthing person's readiness for discharge
- B. to ensure the birthing person can ambulate safely
- C. to detect any signs of perineal trauma
- D. to assess the status of cervical dilation
Correct Answer: C
Rationale: The primary purpose of assessing the perineum during the fourth stage of labor is to detect any signs of perineal trauma. This assessment is crucial to identify any tears or lacerations that may require immediate medical attention. By checking for perineal trauma, the nurse can ensure proper healing and prevent complications postpartum.
Summary:
A: Evaluating readiness for discharge is not the primary purpose of perineal assessment during the fourth stage of labor.
B: Ensuring safe ambulation is important but not the primary reason for assessing the perineum.
D: Assessing cervical dilation is not relevant during the fourth stage of labor where the focus shifts to monitoring postpartum recovery.
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The nurse is reading an article that states that the maternal mortality rate in the United States in the year 2000 was 17. Which of the following statements would be an accurate interpretation of the statement?
- A. There were 17 maternal deaths in the United States in 2,000 per 100,000 live births.
- B. There were 17 maternal deaths in the United States in 2,000 per 100,000 women of childbearing age.
- C. There were 17 maternal deaths in the United States in 2,000 per 100,000 pregnancies.
- D. There were 17 maternal deaths in the United States in 2,000 per 100,000 women in the country
Correct Answer: A
Rationale: Maternal mortality rates are typically expressed as the number of maternal deaths per 100,000 live births. This metric focuses specifically on deaths related to pregnancy or childbirth complications among women who have given birth, making option A the correct choice. Options B, C, and D refer to broader populations or less relevant denominators, which do not align with standard definitions of maternal mortality rates.
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 24 weeks gestation is concerned about gestational diabetes. Which of the following is the most important aspect of managing this condition?
- A. Increasing physical activity and monitoring blood glucose levels.
- B. Administering insulin to control blood sugar levels.
- C. Eating larger meals to prevent hypoglycemia.
- D. Limiting fluid intake to reduce blood sugar fluctuations.
Correct Answer: A
Rationale: The correct answer is A: Increasing physical activity and monitoring blood glucose levels. This is because physical activity helps improve insulin sensitivity and manage blood glucose levels in gestational diabetes. Monitoring blood glucose levels is essential to ensure they are within the target range for both the mother and baby's health. Administering insulin (B) may be necessary in some cases but is not the first-line approach. Eating larger meals (C) can lead to higher blood sugar levels and does not prevent hypoglycemia. Limiting fluid intake (D) is not recommended as it can lead to dehydration and does not directly impact blood sugar fluctuations.
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 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.