Nokea
The nurse is caring for a pregnant patient who is 37 weeks gestation and is experiencing contractions every 10 minutes. Which of the following should the nurse assess first?
- A. The patient's vital signs and fetal heart rate
- B. The patient's cervical dilation and effacement
- C. The patient's urinary output and fluid balance
- D. The patient's emotional status and support system
Correct Answer: B
Rationale: The correct answer is B: The patient's cervical dilation and effacement. At 37 weeks gestation with contractions every 10 minutes, assessing cervical dilation and effacement is crucial to determine if the patient is in active labor. This information will guide the nurse in determining the appropriate next steps for the patient's care, such as the need for further monitoring or interventions. Assessing vital signs and fetal heart rate (Choice A) is important but not the priority in this scenario. Urinary output and fluid balance (Choice C) are important considerations but not the immediate priority. Emotional status and support system (Choice D) are also important but not the first assessment to be made in this situation.
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A nurse is assessing a laboring person for signs of uterine rupture. What is the most common sign of uterine rupture?
- A. abdominal pain
- B. vaginal bleeding
- C. decreased fetal movement
- D. increased fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: decreased fetal movement. Uterine rupture can lead to decreased blood flow to the fetus, resulting in reduced fetal movement. This sign is crucial as it indicates fetal distress and the need for immediate medical intervention. Abdominal pain (A) can be present but is not specific to uterine rupture. Vaginal bleeding (B) is a sign of placental abruption, not uterine rupture. Increased fetal heart rate (D) can occur due to fetal distress, but decreased fetal movement is a more direct sign of uterine rupture.
What fetal change occurs when the fundal height reaches the xiphoid process?
- A. Surfactant forms in lungs
- B. Eyes begin to open and close
- C. Respiratory movements begin
- D. Spinal column is complete
Correct Answer: A
Rationale: Surfactant production begins in the lungs around this stage of pregnancy, preparing them for postnatal breathing.
A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?
- A. verify the person's immunization history
- B. obtain informed consent
- C. check for signs of an allergic reaction
- D. ensure proper positioning for the vaccine
Correct Answer: D
Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.
During the first stage of labor, what is the primary goal of nursing care in the early phase?
- A. Administer pain medication.
- B. Monitor fetal heart rate continuously.
- C. Promote relaxation and provide comfort measures.
- D. Prepare for imminent delivery.
Correct Answer: C
Rationale: The correct answer is C because during the early phase of labor, the primary goal of nursing care is to promote relaxation and provide comfort measures to help the mother cope with contractions and manage pain. This helps create a calm and supportive environment, enhancing the progress of labor. Administering pain medication (A) may be necessary later, not necessarily in the early phase. Monitoring fetal heart rate continuously (B) is important but not the primary goal in the early phase. Preparing for imminent delivery (D) is premature in the early phase, as labor can be lengthy.
A 35-week pregnant woman presents with ruptured membranes. What is the priority intervention?
- A. Check for cord prolapse
- B. Monitor for fetal distress
- C. Administer antibiotics
- D. Perform a vaginal exam to assess cervical dilation
Correct Answer: A
Rationale: The correct answer is A: Check for cord prolapse. This is the priority intervention because with ruptured membranes, there is a risk of umbilical cord prolapse, which can lead to fetal compromise. Checking for cord prolapse allows for quick identification and immediate intervention to prevent potential harm to the baby.
Choice B is incorrect as monitoring for fetal distress is important but not the immediate priority when cord prolapse is a concern. Choice C, administering antibiotics, may be necessary but does not address the immediate risk of cord prolapse. Choice D, performing a vaginal exam, can increase the risk of infection and should be avoided until cord prolapse is ruled out.