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During the postpartum period, a nurse is caring for a birthing person who is receiving uterotonic medications. The nurse's assessment reveals a boggy and enlarged uterus. What is the nurse's immediate action?
- A. Document the findings as normal.
- B. Continue to administer the uterotonic medication.
- C. Perform fundal massage to promote uterine firmness.
- D. Administer an analgesic for the birthing person's pain.
Correct Answer: C
Rationale: The correct immediate action is C: Perform fundal massage to promote uterine firmness. Fundal massage helps prevent postpartum hemorrhage by promoting uterine contraction and firmness. A: Documenting the findings as normal is incorrect as a boggy and enlarged uterus is not a normal finding postpartum. B: Continuing to administer uterotonic medication without addressing the boggy uterus can lead to ineffective contraction. D: Administering an analgesic for pain does not address the underlying issue of uterine atony.
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A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
- A. ensure the birthing person is positioned correctly
- B. check for allergies to anesthesia
- C. administer a test dose of anesthesia
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
What is the priority intervention for a laboring person with a suspected uterine rupture?
- A. prepare for an emergency cesarean section
- B. perform uterine massage
- C. apply pressure to the abdomen
- D. monitor the fetal heart rate continuously
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation.
Incorrect choices:
A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial.
C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications.
D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.
A woman missed her menstrual period 1 week ago and has come to the doctor’s office for a pregnancy test. Which placental hormone is measured in pregnancy tests?
- A. Progesterone
- B. Estrogen
- C. Human chorionic gonadotropin
- D. Human placental lactogen
Correct Answer: C
Rationale: Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.
A nurse is caring for a laboring person in the first stage of labor. What is the priority assessment during this stage?
- A. assess fetal heart rate
- B. monitor contractions
- C. administer oxytocin
- D. check for cervical dilation
Correct Answer: A
Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring fetal well-being is the priority to ensure the baby's safety. Assessing the fetal heart rate helps determine if the baby is tolerating labor well. Monitoring contractions (B) is important but assessing the fetal heart rate takes precedence. Administering oxytocin (C) should be done based on specific indications and not as a routine assessment during the first stage of labor. Checking for cervical dilation (D) is important but does not take priority over assessing fetal well-being.
A pregnant patient at 30 weeks gestation reports swelling in her legs and feet. Which intervention is most appropriate for the nurse to recommend?
- A. Encourage the patient to elevate her legs and rest regularly.
- B. Increase sodium intake to help with fluid retention.
- C. Administer diuretics to reduce swelling and fluid retention.
- D. Instruct the patient to avoid drinking fluids to decrease swelling.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to elevate her legs and rest regularly. This intervention is appropriate because elevating the legs helps reduce swelling by promoting venous return and decreasing fluid accumulation in the lower extremities. Resting regularly also helps reduce the strain on the circulatory system.
Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and swelling. Choice C is incorrect because administering diuretics during pregnancy can pose risks to the fetus and should only be done under medical supervision. Choice D is incorrect because limiting fluid intake can lead to dehydration and is not recommended during pregnancy, especially when experiencing swelling.