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How often should the nurse assess the blood pressure, pulse, and respirations of the birthing person during the first hour of the fourth stage of labor?
- A. every 15 minutes
- B. every 30 minutes
- C. not until after the first hour
- D. once, then hourly
Correct Answer: A
Rationale: The correct answer is A: every 15 minutes. During the first hour of the fourth stage of labor, immediate postpartum assessment is crucial to monitor for any signs of complications such as hemorrhage or shock. Assessing vital signs every 15 minutes allows for early detection of any abnormalities and prompt intervention. This frequency ensures close monitoring of the birthing person's condition and helps in early identification of any potential issues. Choices B, C, and D are incorrect because less frequent assessments may delay the identification of complications, potentially leading to serious consequences. Option C, in particular, is dangerous as it suggests delaying assessments when immediate postpartum monitoring is essential.
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The nurse is caring for a pregnant patient who is 24 weeks gestation and reports nausea, vomiting, and weight loss. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to eat a high-protein diet and avoid fluids during meals.
- B. Encourage the patient to rest and avoid any exercise.
- C. Assess the patient's hydration status and notify the healthcare provider if necessary.
- D. Recommend over-the-counter anti-nausea medications to control symptoms.
Correct Answer: C
Rationale: The correct answer is C: Assess the patient's hydration status and notify the healthcare provider if necessary.
Rationale:
1. Nausea, vomiting, and weight loss in pregnancy may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances.
2. Assessing hydration status is crucial to determine the severity of the condition and guide appropriate interventions.
3. Notifying the healthcare provider allows for further evaluation, possible treatment adjustments, and monitoring to prevent complications.
Summary:
A: Instructing the patient to eat a high-protein diet and avoid fluids during meals does not address the immediate concern of dehydration and may worsen symptoms.
B: Encouraging the patient to rest and avoid exercise is important but does not address the primary issue of dehydration.
D: Recommending over-the-counter anti-nausea medications may provide symptomatic relief but does not address the underlying cause or hydration status.
Organize the developmental stages in the correct order. Put a comma and space between each answer choice (a, b, c, d, etc.)
- A. Zygote
- B. Morula
- C. Blastocyst
- D. Embryo
Correct Answer: B
Rationale: Fetal development progresses through several stages: zygote, morula, blastocyst, embryo, and fetus. Each stage represents a critical phase in the formation and growth of the embryo.
A 22-year-old woman presents to the labor and delivery unit in labor at 39 weeks gestation. Her cervix is 6 cm dilated and 100% effaced. What should the nurse do next?
- A. Prepare for delivery
- B. Administer pain relief medications
- C. Continue to monitor contractions and fetal heart rate
- D. Perform a vaginal examination to check for fetal descent
Correct Answer: C
Rationale: The correct answer is C: Continue to monitor contractions and fetal heart rate. At 6 cm dilated and 100% effaced, the woman is in active labor, but delivery is not imminent. Monitoring contractions and fetal heart rate is crucial to ensure the progress of labor and fetal well-being. This step allows the nurse to assess for any signs of fetal distress or labor progression. Administering pain relief medications (B) can be considered based on the woman's pain level, but it is not the immediate priority. Preparing for delivery (A) is premature at this stage. Performing a vaginal examination (D) may not be necessary unless there are concerns about fetal descent or progress of labor.
Which of the following skin changes should the nurse highlight for a pregnant woman’s health care practitioner?
- A. Linea nigra.
- B. Melasma.
- C. Petechiae.
- D. Spider nevi.
Correct Answer: C
Rationale: Petechiae (small hemorrhages under the skin) could indicate underlying medical conditions such as thrombocytopenia or coagulopathy, warranting further investigation. Linea nigra and melasma are common benign changes, while spider nevi are usually harmless but less urgent.
What is the most important nursing intervention for a laboring person with an epidural who has a low blood pressure?
- A. increase the IV fluid rate
- B. administer an epidural bolus
- C. administer an analgesic
- D. increase the frequency of monitoring
Correct Answer: A
Rationale: The correct answer is A: increase the IV fluid rate. This intervention helps to increase blood volume and improve blood pressure, addressing hypotension commonly caused by epidural anesthesia. Administering an epidural bolus (B) can worsen hypotension. Administering an analgesic (C) is not the priority in this situation. Increasing monitoring frequency (D) is important but addressing the underlying cause of low blood pressure is crucial.