Pregnant patients can usually tolerate the normal blood loss associated with childbirth because of which physiologic adaptation to pregnancy?
- A. A higher hematocrit
- B. Increased leukocytes
- C. Increased blood volume
- D. A lower fibrinogen level
Correct Answer: C
Rationale: The correct answer is C: Increased blood volume. During pregnancy, blood volume increases by about 40-50% to support the growing fetus and prepare for potential blood loss during childbirth. This increased blood volume helps pregnant patients tolerate the normal blood loss during delivery. A higher hematocrit (choice A) could indicate dehydration, not increased blood volume. Increased leukocytes (choice B) are related to the immune response, not blood loss tolerance. A lower fibrinogen level (choice D) could lead to increased bleeding risk, not tolerance to blood loss.
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Which of the following are signs of impending labor? Select all that apply.
- A. Weight gain
- B. Surge of energy
- C. Increase in urinary frequency
- D. Dyspnea
Correct Answer: B
Rationale: The correct answer is B: Surge of energy. This is a sign of impending labor because some women experience a burst of energy as the body prepares for childbirth. Weight gain (A) is not a typical sign of impending labor, as weight gain usually occurs earlier in pregnancy. Increase in urinary frequency (C) is a common symptom throughout pregnancy and may not specifically indicate impending labor. Dyspnea (D), which is difficulty breathing, is not typically a sign of impending labor unless it is due to specific complications.
What anticipatory guidance should the nurse provide for new parents regarding sociologic changes?
- A. Explain that roles will not change at home
- B. Explain that stresses will be over now that the newborn is born.
- C. Tell the parents not to stress over household changes.
- D. Prepare them for possible strains on relationships.
Correct Answer: D
Rationale: The correct answer is D: Prepare them for possible strains on relationships. This guidance is important as the arrival of a newborn can bring significant changes to the dynamics of a relationship. By preparing new parents for possible strains on relationships, the nurse can help them navigate challenges together.
A: Incorrect. Roles are likely to change at home with the addition of a newborn, so it is important to address this rather than dismissing it.
B: Incorrect. Stressors may actually increase with the arrival of a newborn, so it is not accurate to say stresses will be over.
C: Incorrect. Ignoring household changes can lead to added stress, so it is not advisable to tell parents not to stress over them.
In summary, option D is correct as it addresses the potential strains on relationships that new parents may face, while the other options do not acknowledge the reality of sociologic changes that can occur.
To determine if the patient is in true labor, the nurse would assess for changes in
- A. cervical dilation.
- B. amount of bloody show.
- C. fetal position and station.
- D. pattern of uterine contractions.
Correct Answer: D
Rationale: The correct answer is D: pattern of uterine contractions. This is because the pattern of contractions is a key indicator of true labor. True labor contractions are regular, increasing in frequency, duration, and intensity. Assessing the pattern helps differentiate true labor from false labor.
A: Cervical dilation is important but may not necessarily indicate true labor as it can occur in false labor as well.
B: The amount of bloody show is a sign of cervical changes, but it alone does not confirm true labor.
C: Fetal position and station are important for labor progress but do not definitively confirm true labor.
In summary, assessing the pattern of uterine contractions is crucial in determining true labor as it provides direct insight into the progression and intensity of contractions, distinguishing it from false labor.
The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
- A. Offer the patient a warm blanket.
- B. Place an ice pack on the perineum.
- C. Massage the uterus if it is boggy.
- D. Delay breastfeeding until the patient is reste
Correct Answer: A
Rationale: The correct answer is A: Offer the patient a warm blanket. In the fourth stage of labor, the mother experiences postpartum hemorrhage risk due to uterine atony. Keeping the patient warm helps prevent hypothermia, which can lead to increased bleeding. Ice packs (B) are not indicated as they can cause vasoconstriction and inhibit proper blood flow. Massaging the uterus (C) is appropriate in the third stage of labor to prevent hemorrhage but not in the fourth stage. Delaying breastfeeding (D) is incorrect as early breastfeeding promotes uterine contractions, reducing the risk of postpartum hemorrhage.
The nurse is directing an unlicensed assistive personnel (UAP) to obtain maternal vital signs between contractions. Which statement is the appropriate rationale for assessing maternal vital signs between contractions raNtheRr thaIn aGt anBot.heCr inMterval? U S N T O
- A. Vital signs taken during contractions are inaccurat
- B. During a contraction, assessing fetal heart rate is the priority.
- C. Maternal blood flow to the heart is reduced during contractions.
- D. Maternal circulating blood volume increases temporarily during contractions.
Correct Answer: D
Rationale: The correct answer is D. During contractions, maternal circulating blood volume increases temporarily due to the compression of blood vessels. Therefore, assessing vital signs between contractions provides a more accurate baseline measurement. Choice A is incorrect because vital signs taken during contractions may be affected by the pain and stress of labor. Choice B is incorrect as fetal heart rate assessment is a separate priority. Choice C is incorrect as maternal blood flow to the heart actually increases during contractions to ensure adequate oxygen supply.