Nokea
The nurse is caring for a pregnant patient who is 38 weeks gestation and reports feeling pelvic pressure and mild cramping. What should the nurse do first?
- A. Monitor the fetal heart rate and check for signs of labor.
- B. Instruct the patient to rest and monitor the symptoms.
- C. Assess the patient's blood pressure and urine for protein.
- D. Perform a pelvic exam to assess for cervical dilation.
Correct Answer: A
Rationale: The correct answer is A because monitoring the fetal heart rate and checking for signs of labor are essential in assessing the well-being of the fetus and determining if the patient is in active labor. This step helps the nurse identify any potential complications and take appropriate actions promptly.
Choice B is incorrect because simply instructing the patient to rest may not address the underlying cause of pelvic pressure and cramping.
Choice C is incorrect as assessing blood pressure and urine for protein is not the priority in this situation.
Choice D is incorrect because performing a pelvic exam should be done after monitoring fetal well-being and ruling out active labor.
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Which of the following is a common cause of uterine atony?
- A. uterine overdistention
- B. excessive uterine contractions
- C. placental abruption
- D. infection or retained placenta
Correct Answer: A
Rationale: The correct answer is A: uterine overdistention. Uterine atony is when the uterus fails to contract effectively after childbirth. Overdistention, such as from multiple gestation or large baby, can stretch the uterus, leading to poor muscle tone. This results in inadequate contractions to control bleeding. Excessive uterine contractions (B) are not a common cause but rather can lead to other issues like uterine rupture. Placental abruption (C) is the premature separation of the placenta from the uterus, causing bleeding but not directly related to atony. Infection or retained placenta (D) can contribute to uterine atony but are not common primary causes.
A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most important intervention to prevent DVT?
- A. administer anticoagulants
- B. administer IV fluids
- C. perform leg exercises
- D. ensure early ambulation
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate hydration which prevents blood from becoming too thick and reduces the risk of clot formation. Adequate hydration also promotes blood circulation, decreasing the risk of DVT. Administering anticoagulants (choice A) is important in managing DVT but is not the most important preventive intervention. Performing leg exercises (choice C) and ensuring early ambulation (choice D) are also beneficial in preventing DVT, but maintaining hydration with IV fluids is the most crucial intervention as it directly addresses the primary factor contributing to DVT formation.
A nurse is educating a postpartum person about newborn care. Which of the following should be included in the teaching about umbilical cord care?
- A. keep the cord dry and clean
- B. apply a sterile dressing to the cord
- C. use alcohol or iodine to clean the cord
- D. apply a sterile dressing to the umbilicus
Correct Answer: A
Rationale: The correct answer is A: keep the cord dry and clean. This is because keeping the umbilical cord dry and clean helps prevent infection and promotes healing. Applying a sterile dressing (B) is unnecessary and may trap moisture, leading to infection. Using alcohol or iodine (C) is outdated and can delay cord separation. Applying a sterile dressing to the umbilicus (D) is not recommended as it can interfere with air circulation and healing. In summary, choice A is correct as it aligns with current best practices for umbilical cord care.
A nurse is caring for a pregnant patient who is at 20 weeks gestation and reports experiencing leg cramps. What is the nurse's most appropriate intervention?
- A. Recommend taking calcium supplements to relieve leg cramps.
- B. Encourage the patient to elevate the legs and perform leg stretches.
- C. Instruct the patient to rest and avoid any physical activity.
- D. Administer pain medication as needed.
Correct Answer: B
Rationale: The correct answer is B because elevating the legs and performing leg stretches can help improve circulation and relieve leg cramps during pregnancy. This intervention promotes blood flow and prevents muscle fatigue. Calcium supplements (choice A) may be helpful for preventing leg cramps in some cases but are not the first-line intervention. Instructing the patient to rest (choice C) may worsen leg cramps due to decreased circulation. Administering pain medication (choice D) should be avoided unless necessary, as it does not address the root cause of the leg cramps.
A pregnant patient is at 28 weeks gestation and reports leg cramps. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to stretch the legs and elevate them to alleviate the cramps.
- B. Recommend that the patient increase calcium intake through dietary changes.
- C. Administer prescribed pain medication to relieve discomfort.
- D. Encourage the patient to walk for 30 minutes each day to prevent cramps.
Correct Answer: A
Rationale: The correct answer is A. Leg cramps during pregnancy are common due to increased weight and pressure on leg muscles. Stretching and elevating legs can help alleviate cramps by improving circulation and reducing muscle tension. Increasing calcium intake (B) may help prevent cramps but is not the immediate action needed. Administering pain medication (C) should be avoided unless absolutely necessary. Walking (D) is beneficial for overall health during pregnancy but may not directly address the immediate leg cramps.