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The nurse who will care for a patient in labor receives a report and is told that the patient's status is as follows: 4 cm, 50%, and +1 station. What should be the nurse's interpretation of this information?
- A. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm below the ischial spines.
- B. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm above the ischial spines.
- C. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm below the ischial spines.
- D. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm above the ischial spines.
Correct Answer: C
Rationale: The correct interpretation is C because in labor progress, cervical dilation (4 cm) refers to how much the cervix has opened, effacement (50%) indicates the thinning of the cervix, and station (+1) describes the descent of the baby's head in relation to the ischial spines. Therefore, the nurse should understand that the cervix is dilated 4 cm, effaced 50%, and the baby's head is 1 cm below the ischial spines, which is indicative of progressing labor.
Choice A is incorrect because it incorrectly describes the station as being 1 cm below the ischial spines instead of above. Choice B is incorrect as it inaccurately states that the cervix is effaced to 50% rather than dilated. Choice D is incorrect because it states that the cervix is effaced 4 cm, which is not a correct representation of effacement.
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The nurse is educating a pregnant patient on the importance of prenatal care. Which statement by the patient indicates the need for further teaching?
- A. Prenatal visits are important to monitor my baby's growth and development.
- B. Prenatal care helps to identify any complications early on.
- C. I will only need to see the doctor once during my pregnancy if everything goes well.
- D. Regular prenatal visits help ensure that I am maintaining good health during pregnancy.
Correct Answer: C
Rationale: The correct answer is C because it suggests a misconception that the patient only needs to see the doctor once during pregnancy. This is incorrect as prenatal care involves multiple visits to monitor both the mother's and baby's health. A: Correct - Prenatal visits monitor baby's growth. B: Correct - Early detection of complications is crucial. D: Correct - Regular visits ensure the mother's health. C: Incorrect - Seeing the doctor only once is inadequate prenatal care and can lead to missed opportunities for early intervention.
The nurse asks a woman about how the woman’s husband is dealing with the pregnancy.
- A. My husband is ready for the pregnancy to end so that we can have sex again.
- B. My husband has gained quite a bit of weight during this pregnancy.
- C. My husband seems more worried about our finances now than before the pregnancy.
- D. My husband plays his favorite music for my belly so the baby will learn to like it.
Correct Answer: A
Rationale: If the husband is overly focused on resuming sexual activity postpartum, it might indicate a lack of emotional support for the pregnant partner, warranting counseling.
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.
The nurse is providing prenatal education to a pregnant patient at 20 weeks gestation. Which of the following actions should the nurse prioritize?
- A. Assessing the patient for signs of gestational hypertension.
- B. Encouraging the patient to avoid all forms of exercise.
- C. Reviewing newborn care practices and breastfeeding options.
- D. Discussing the signs and symptoms of preterm labor.
Correct Answer: D
Rationale: The correct answer is D: Discussing the signs and symptoms of preterm labor. This is crucial at 20 weeks gestation as preterm labor can occur. By educating the patient on the signs and symptoms, the nurse can empower her to recognize and seek prompt medical attention if needed. Assessing for gestational hypertension (A) is important but typically done later in pregnancy. Encouraging avoidance of all forms of exercise (B) is not recommended as moderate exercise is beneficial during pregnancy. Reviewing newborn care practices and breastfeeding options (C) is important but not the priority at this stage.
The nurse is educating a pregnant patient about the importance of prenatal vitamins. Which statement by the patient indicates effective teaching?
- A. I will take prenatal vitamins only during the first trimester.
- B. I will take prenatal vitamins throughout the pregnancy to support my baby's growth.
- C. Prenatal vitamins are only necessary if I have a history of birth defects in my family.
- D. I should stop taking prenatal vitamins after the baby is born.
Correct Answer: B
Rationale: The correct answer is B: "I will take prenatal vitamins throughout the pregnancy to support my baby's growth." This statement indicates effective teaching because prenatal vitamins are essential for the entire duration of pregnancy to support the developing baby's growth and development. Prenatal vitamins contain key nutrients like folic acid, iron, and calcium that are crucial for the health of both the mother and the baby throughout the pregnancy. Taking prenatal vitamins only during the first trimester (option A) may not provide adequate support for the baby's growth during the entire pregnancy. Option C is incorrect because prenatal vitamins are recommended for all pregnant women, regardless of their family history of birth defects. Option D is incorrect because stopping prenatal vitamins after the baby is born does not align with the need to support the mother's postpartum health and potential breastfeeding needs.