Nokea
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
- A. The nurse midwife saw that the mucous plug was intact.
- B. The nurse midwife felt the baby rebound after being pushed.
- C. The nurse midwife palpated the fetal parts through the uterine wall.
- D. The nurse midwife assessed that the baby is head down.
Correct Answer: B
Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.
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A nurse is caring for a postpartum person who is breastfeeding. What is the most important action to promote effective breastfeeding?
- A. assist with positioning
- B. administer analgesics
- C. administer IV fluids
- D. assist with breastfeeding positioning
Correct Answer: B
Rationale: The correct answer is B: administer analgesics. Pain management is crucial to promote effective breastfeeding as it can help the postpartum person be more comfortable and relaxed during breastfeeding sessions. This can lead to better latch and milk transfer, ultimately enhancing the breastfeeding experience.
A: assist with positioning - While positioning is important for successful breastfeeding, it is not the most crucial action compared to pain management.
C: administer IV fluids - IV fluids are not directly related to promoting effective breastfeeding. Hydration is important but not the most critical factor in this scenario.
D: assist with breastfeeding positioning - This choice is similar to option A and while important, it is not as critical as ensuring proper pain management for effective breastfeeding.
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 caring for a postpartum person who is breastfeeding. What is the most appropriate intervention for sore nipples?
- A. apply lanolin cream
- B. administer IV fluids
- C. perform uterine massage
- D. apply cold compress
Correct Answer: A
Rationale: The correct answer is A: apply lanolin cream. Lanolin cream helps soothe and moisturize sore nipples, providing relief during breastfeeding. It is safe for both the mother and the baby. Applying lanolin cream after each feeding can prevent further irritation and promote healing.
Incorrect choices:
B: Administering IV fluids is not indicated for sore nipples.
C: Performing uterine massage is unrelated to treating sore nipples.
D: Applying cold compress may provide temporary relief but does not address the underlying issue of sore nipples.
Which food can a lactose-intolerant pregnant woman consume for calcium?
- A. Turnip greens
- B. Green beans
- C. Cantaloupe
- D. Nectarines
Correct Answer: A
Rationale: Turnip greens are rich in calcium, making them a suitable alternative for lactose-intolerant individuals.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and reports leaking clear fluid. What is the nurse's priority action?
- A. Check the fetal heart rate and assess the mother's vital signs.
- B. Encourage the patient to go home and rest until contractions begin.
- C. Instruct the patient to monitor fetal movement and call back if the fluid continues to leak.
- D. Call the healthcare provider immediately to report the rupture of membranes.
Correct Answer: D
Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.