Nokea
Five minutes after delivery of the infant, the umbilical cord is protruding more from the woman's vaginal introitus and there is a sudden gush of blood with a contracted uterus. What does this signal to the nurse?
- A. Laceration of the genital tract
- B. The second stage of labor
- C. Separation of the placenta
- D. Postpartum hemorrhage
Correct Answer: C
Rationale: The sudden gush of blood and the contracted uterus indicate a separation of the placenta, which is a serious complication called placental abruption. This condition can lead to significant bleeding and jeopardize the health of both the mother and the baby. It is essential for the nurse to recognize this situation promptly and take immediate action to manage the hemorrhage and stabilize the patient.
Explanation for incorrect choices:
A: Laceration of the genital tract would not typically cause a sudden gush of blood and a contracted uterus.
B: The second stage of labor is characterized by the delivery of the baby, not by a sudden gush of blood and a contracted uterus.
D: Postpartum hemorrhage could be a consequence of placental separation, but it is not the primary issue indicated by the symptoms described in the scenario.
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A pregnant patient with a BMI of 35 is concerned about health effects she and her baby may face during pregnancy. During routine testing, the patient tested negative for sexually transmitted illnesses (STIs) and indicated that she is in a committed, long-term relationship with the child's father. Which of the following is accurate?
- A. The patient's infant is at increased risk of neonatal blindness.
- B. The patient's infant has a decreased risk of birth injury.
- C. The patient will have increased risk of wound infection.
- D. The patient will have a decreased risk of preeclampsia.
Correct Answer: C
Rationale: Rationale:
1. Pregnancy with a high BMI increases the risk of wound infection post-delivery due to delayed wound healing and increased tissue trauma.
2. Negative STI test and committed relationship decrease risks of neonatal blindness and birth injury.
3. Wound infection risk is directly related to BMI and not affected by STI status or relationship status.
Summary:
A: Incorrect - No connection between STI status or relationship status with neonatal blindness.
B: Incorrect - No direct relation between STI status or relationship status with birth injury risk.
D: Incorrect - Preeclampsia risk is not influenced by STI status or relationship status.
A pregnant patient at 26 weeks gestation reports dizziness and faintness when standing. Which intervention should the nurse prioritize?
- A. Encourage the patient to drink plenty of fluids and avoid standing for long periods.
- B. Instruct the patient to rise quickly from a seated position.
- C. Encourage the patient to lie flat on her back and rest.
- D. Advise the patient to take iron supplements to prevent dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink plenty of fluids and avoid standing for long periods. This intervention addresses the symptoms of dizziness and faintness by preventing dehydration and orthostatic hypotension common during pregnancy. Fluid intake maintains blood volume, reducing the risk of hypotension. Avoiding prolonged standing helps prevent blood pooling in the lower extremities. Choices B and C could exacerbate symptoms by causing sudden changes in blood pressure. Choice D is incorrect as iron supplements do not directly address the immediate issue of dizziness and faintness related to dehydration and orthostatic hypotension during pregnancy.
The nurse is caring for a pregnant patient who is 36 weeks gestation and is concerned about the upcoming delivery. Which of the following statements by the nurse is most appropriate?
- A. Labor will likely be quick and easy, especially since this is your first pregnancy.
- B. Labor can be unpredictable, and each birth is different.
- C. You will probably need a cesarean section since you are at full term.
- D. You may not feel any pain during labor because of modern pain relief options.
Correct Answer: B
Rationale: The correct answer is B: "Labor can be unpredictable, and each birth is different." This response acknowledges the variability and individuality of labor experiences, providing reassurance to the patient. Labor outcomes depend on various factors such as maternal health, baby's position, and other unforeseen circumstances.
Explanation:
1. A (Labor will likely be quick and easy, especially since this is your first pregnancy): This statement is incorrect because the duration and ease of labor are not solely determined by the patient's parity (number of pregnancies). Each labor is unique and may vary in length and intensity regardless of previous pregnancies.
2. C (You will probably need a cesarean section since you are at full term): This statement is incorrect as the majority of pregnant women deliver vaginally at full term. Cesarean section is not a predetermined outcome solely based on gestational age.
3. D (You may not feel any pain during labor because of modern pain relief options): This statement is incorrect because pain
A woman in labor begins to experience severe lower abdominal pain and is found to have a ruptured uterus. What is the first intervention the nurse should perform?
- A. Administer intravenous fluids
- B. Prepare the patient for immediate surgery
- C. Perform a vaginal examination
- D. Administer pain relief medications
Correct Answer: B
Rationale: The correct answer is B: Prepare the patient for immediate surgery. In the case of a ruptured uterus, prompt surgical intervention is crucial to control bleeding, repair the uterus, and prevent further complications such as hemorrhage and infection. Performing surgery is the priority over other interventions like administering fluids, pain relief medications, or performing a vaginal examination, as these actions do not address the immediate life-threatening situation of uterine rupture. Administering IV fluids may be necessary during surgery, and pain relief can be addressed post-operatively. Vaginal examination is contraindicated in cases of suspected uterine rupture as it can exacerbate the bleeding and worsen the condition.
A nurse is preparing a laboring person for an emergency cesarean birth. What is the most important nursing intervention prior to the procedure?
- A. administer a preoperative medication
- B. administer pain relief
- C. administer an epidural block
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: administer a preoperative medication. This is crucial prior to an emergency cesarean birth to ensure the person is adequately prepared for the procedure. Preoperative medications can help reduce anxiety, prevent complications such as aspiration during anesthesia induction, and promote smooth recovery post-surgery. Administering pain relief (B) and epidural block (C) may be important for comfort but are not the priority in this urgent situation. Administering IV fluids (D) is generally important in preparation for surgery, but administering preoperative medication takes precedence in this scenario to ensure the person's safety and well-being during the emergency cesarean birth.