Nokea
The nurse is teaching a pregnant patient about preparing for childbirth. Which of the following statements by the patient indicates that further teaching is needed?
- A. I will practice breathing exercises to help manage labor pain.
- B. I should plan to stay in bed during labor to conserve my energy.
- C. I will learn about different labor positions to make the experience more comfortable.
- D. I should discuss pain relief options with my healthcare provider ahead of time.
Correct Answer: B
Rationale: The correct answer is B. Staying in bed during labor is not recommended as it can slow down labor progress and increase discomfort.
Rationale:
1. A: Correct - Breathing exercises help manage pain and promote relaxation during labor.
2. C: Correct - Learning about different labor positions can ease pain and facilitate labor progress.
3. D: Correct - Discussing pain relief options with healthcare provider is important for informed decision-making.
Summary:
Choice B is incorrect as it goes against best practices for labor. The other choices demonstrate understanding of labor preparation and pain management strategies.
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A client enters the prenatal clinic. She states that she believes she is pregnant. Which of the following hormone elevations will indicate a high probability that the client is pregnant?
- A. Chorionic gonadotropin.
- B. Oxytocin.
- C. Prolactin.
- D. Luteinizing hormone.
Correct Answer: A
Rationale: Chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests and is a definitive indicator of pregnancy. Oxytocin, prolactin, and luteinizing hormone are not specific to pregnancy.
The embryo is termed a fetus at which stage of prenatal development?
- A. 2 weeks
- B. 4 weeks
- C. 9 weeks
- D. 16 weeks
Correct Answer: C
Rationale: The fetus (third stage of prenatal development) begins at the ninth week and continues until the 40th week of gestation or until birth.
A patient who is 40 weeks pregnant and is in labor suddenly complains of a severe headache and blurry vision. What should the nurse assess for?
- A. Preeclampsia
- B. Fetal distress
- C. Uterine rupture
- D. Placenta previa
Correct Answer: A
Rationale: The correct answer is A: Preeclampsia. In this scenario, the sudden onset of severe headache and blurry vision in a pregnant woman in labor are indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and signs of organ damage. The nurse should assess for other symptoms of preeclampsia such as hypertension, proteinuria, edema, and epigastric pain. Preeclampsia can lead to eclampsia, seizures, and life-threatening complications for both the mother and the baby if not promptly managed.
Summary:
B: Fetal distress - Not the priority assessment when the mother is experiencing symptoms indicative of a serious maternal condition like preeclampsia.
C: Uterine rupture - Symptoms are not suggestive of uterine rupture, which typically presents with severe abdominal pain, vaginal bleeding, and signs of shock.
D: Placenta previa - Symptoms are not consistent with placenta previa, which typically
A patient in labor is at 6 cm dilation and requests an epidural. What is the most appropriate response from the nurse?
- A. You need to be at least 8 cm dilated for an epidural.
- B. You can have the epidural now since you are in active labor.
- C. The epidural can be administered after the second stage of labor.
- D. An epidural is only administered during the latent phase of labor.
Correct Answer: B
Rationale: The correct answer is B: "You can have the epidural now since you are in active labor." At 6cm dilation, the patient is typically considered to be in active labor, making it an appropriate time to offer an epidural for pain relief. Administering the epidural at this stage can help manage the pain effectively and provide relief during the remainder of labor. Other choices are incorrect because waiting until 8cm dilation (Choice A) may cause unnecessary suffering, administering after the second stage (Choice C) is too late for pain relief, and giving it during the latent phase (Choice D) is not ideal as the patient may not be in active labor yet.
What is the primary nursing action when a laboring person experiences a ruptured uterus?
- A. prepare for an emergency cesarean section
- B. provide immediate pain relief
- C. apply oxygen via mask
- D. apply pressure to the abdomen
Correct Answer: C
Rationale: The correct answer is C: apply oxygen via mask. This is the primary nursing action for a ruptured uterus because it helps improve oxygenation to the laboring person and the fetus. Ruptured uterus can lead to a significant decrease in oxygen supply, so providing oxygen is crucial.
Incorrect choices:
A: preparing for an emergency cesarean section is important but not the primary action in this situation.
B: providing pain relief is important, but ensuring oxygenation is a higher priority.
D: applying pressure to the abdomen is not recommended as it can worsen the condition.