Nokea
The nurse is educating a pregnant patient at 30 weeks gestation on the signs and symptoms of preterm labor. Which of the following should the nurse instruct the patient to report immediately?
- A. Mild cramping and back pain.
- B. Increased vaginal discharge.
- C. Regular contractions every 10 minutes or less.
- D. Feeling of pelvic pressure after physical activity.
Correct Answer: C
Rationale: The correct answer is C. Regular contractions every 10 minutes or less should be reported immediately as they could indicate preterm labor. The frequency and regularity of contractions are key indicators of labor starting. Other choices, A, B, and D, are common discomforts during pregnancy and not necessarily indicative of preterm labor. Mild cramping and back pain (A), increased vaginal discharge (B), and feeling of pelvic pressure after physical activity (D) are normal symptoms in pregnancy and not urgent signs of preterm labor.
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A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head crowns?
- A. apply gentle downward pressure
- B. assist with shoulder delivery
- C. assist with perineal massage
- D. administer pain relief
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of perineal tearing and ensuring a controlled birth. Applying too much pressure can cause trauma to the mother and baby. Incorrect choices: B is premature, as shoulder delivery should only be done after the head and shoulders are delivered. C is not the most important action at crowning. D is not necessary at this specific stage of delivery.
A woman, 6 weeks pregnant, is having a vaginal examination. Which of the following would the practitioner expect to find?
- A. Thin cervical muscle.
- B. An enlarged ovary.
- C. Thick cervical mucus.
- D. Pale pink vaginal wall.
Correct Answer: B
Rationale: An enlarged ovary is a common finding in early pregnancy due to the corpus luteum. Thin cervical muscle, thick cervical mucus, and a pale pink vaginal wall are not typical findings at this stage.
What is true about the morula stage of development?
- A. Fertilized egg has yet to implant
- B. Lung fields are completely formed
- C. Sex of fetus can be identified
- D. Eyelids begin to open and close
Correct Answer: A
Rationale: The morula stage occurs before implantation, representing an early phase of embryonic development.
A patient with a history of gestational diabetes is admitted to the labor and delivery unit. What is the most important factor to monitor during labor?
- A. Maternal blood pressure
- B. Fetal heart rate
- C. Blood glucose levels
- D. Maternal temperature
Correct Answer: C
Rationale: The correct answer is C: Blood glucose levels. During labor, it is crucial to monitor the blood glucose levels of a patient with a history of gestational diabetes to prevent complications such as hyperglycemia or hypoglycemia. Fluctuations in blood glucose levels can impact both the mother and the baby's health. Monitoring maternal blood pressure (A) is important but not the most critical factor in this scenario. Fetal heart rate (B) is essential but does not directly address the specific needs of a patient with a history of gestational diabetes. Maternal temperature (D) is also important but does not take precedence over monitoring blood glucose levels in this case.