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During the third stage of labor, the nurse notes excessive bleeding. What should the nurse assess first?
- A. uterine tone
- B. placental separation
- C. vaginal bleeding
- D. cervical dilation
Correct Answer: A
Rationale: During the third stage of labor, the correct answer is A: uterine tone. This is because assessing uterine tone is crucial in determining if the uterus is contracting effectively to control bleeding. If the uterus is not firm (boggy), it can lead to postpartum hemorrhage. Placental separation (B) occurs during the third stage, but assessing uterine tone takes precedence. Vaginal bleeding (C) is a symptom of potential postpartum hemorrhage, which can be caused by poor uterine tone. Cervical dilation (D) is not a priority in this situation as the focus should be on controlling bleeding.
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The nurse is caring for a pregnant patient who is 30 weeks gestation and reports feeling faint and lightheaded. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to lie on her back to improve circulation.
- B. Encourage the patient to take deep breaths and sit down immediately.
- C. Instruct the patient to stand up slowly and rest for 10 minutes.
- D. Ask the patient to eat something sweet to raise her blood sugar.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to take deep breaths and sit down immediately. This action is appropriate because the patient is experiencing symptoms of hypotension, which can lead to decreased blood flow to the brain causing faintness and lightheadedness. By encouraging the patient to take deep breaths and sit down immediately, the nurse is helping to increase oxygen intake and improve circulation, which can alleviate the symptoms.
Explanation for why the other choices are incorrect:
A: Instructing the patient to lie on her back can actually worsen symptoms as it can lead to a decrease in blood flow to the brain.
C: Instructing the patient to stand up slowly is not appropriate as the patient is already feeling faint and lightheaded. This can increase the risk of falling and injury.
D: Asking the patient to eat something sweet may not address the underlying cause of the symptoms, which is likely related to hypotension. It is important to address the immediate
The nurse is caring for a 14-year-old patient who is 32 weeks pregnant. After complaining of genital sores and discomfort, the patient tests positive for syphilis. The fetus is at increased risk of which condition?
- A. Diabetes
- B. Blindness
- C. Pneumonia
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Blindness. Syphilis infection during pregnancy can lead to congenital syphilis, which can cause a range of complications for the fetus, including blindness. The spirochete that causes syphilis can cross the placenta and affect the developing fetus, leading to various abnormalities. Blindness is a common manifestation of congenital syphilis due to damage to the eyes and optic nerve. The other options are not directly associated with syphilis infection during pregnancy. Diabetes, pneumonia, and hypertension are not typically linked to congenital syphilis and its effects on the fetus. Therefore, the correct answer is B: Blindness.
A pregnant patient is asking about the risks of smoking during pregnancy. Which of the following is the most appropriate response by the nurse?
- A. Smoking during pregnancy is safe if you don't have other complications.
- B. Smoking increases the risk of premature birth, low birth weight, and developmental delays.
- C. It's okay to smoke in moderation during pregnancy as long as you quit before delivery.
- D. Smoking only affects the mother, not the baby.
Correct Answer: B
Rationale: The correct answer is B because smoking during pregnancy significantly increases the risk of adverse outcomes such as premature birth, low birth weight, and developmental delays. Nicotine and other harmful chemicals in cigarettes can restrict oxygen and nutrients to the baby, leading to these complications. Choice A is incorrect as smoking is never safe during pregnancy. Choice C is incorrect as any amount of smoking during pregnancy is harmful. Choice D is incorrect as smoking affects both the mother and the baby due to the harmful substances passing through the placenta.
A nurse is caring for a pregnant patient who is 26 weeks gestation and reports feeling dizzy when standing. What should the nurse recommend to the patient?
- A. Stand up slowly and make sure to drink plenty of fluids.
- B. Sit down immediately and rest for 10 minutes.
- C. Lie flat on your back to increase blood flow to the brain.
- D. Take deep breaths and elevate your legs while sitting.
Correct Answer: A
Rationale: The correct answer is A: Stand up slowly and make sure to drink plenty of fluids. When a pregnant patient feels dizzy when standing, it is likely due to postural hypotension. Standing up slowly helps prevent a sudden drop in blood pressure, which can cause dizziness. Drinking plenty of fluids helps maintain adequate blood volume and prevents dehydration, another common cause of dizziness during pregnancy. Sitting down immediately (B) may help temporarily but does not address the underlying issue. Lying flat on the back (C) can worsen symptoms by putting pressure on the vena cava, reducing blood flow to the brain. Taking deep breaths and elevating legs (D) may not be effective in addressing postural hypotension.
During open glottis pushing, what is the laboring person instructed to do?
- A. hold their breath and push for 10 seconds during each contraction
- B. push spontaneously while exhaling during contractions
- C. exhale slowly during contractions without pushing
- D. perform deep breathing exercises between contractions
Correct Answer: B
Rationale: During open glottis pushing, the correct instruction is for the laboring person to push spontaneously while exhaling during contractions (Choice B). This technique helps prevent breath-holding, which can increase intra-abdominal pressure and reduce blood flow to the heart and baby. Exhaling while pushing allows for better oxygenation and reduces the risk of Valsalva maneuver-related complications. Holding their breath (Choice A) can increase the risk of fetal distress. Exhaling slowly without pushing (Choice C) is not effective in assisting with the pushing stage of labor. Deep breathing exercises between contractions (Choice D) are beneficial for relaxation but not the main focus during pushing.