Nokea
The triage nurse in an obstetric clinic received the following four messages during the lunch hour. Which of the women should the nurse telephone first?
- A. My section incision from last week is leaking a whitish yellow discharge and I have a fever. What should I do?'
- B. I am 39 weeks pregnant with my first baby. I am having contractions about every ten minutes.'
- C. My boyfriend and I had intercourse this morning and our condom broke. What should we do?'
- D. I started my period yesterday. I need some medicine for these terrible menstrual cramps.'
Correct Answer: A
Rationale: A fever and discharge from a surgical incision could indicate an infection, which requires immediate attention. The other situations, while important, are less urgent.
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Which information is covered by early pregnancy classes offered in the first and second trimesters?
- A. Methods of pain relief
- B. The phases and stages of labor
- C. Coping with common discomforts of pregnancy
- D. Prebirth and postbirth care of a patient having a cesarean birth
Correct Answer: C
Rationale: The correct answer is C: Coping with common discomforts of pregnancy. Early pregnancy classes in the first and second trimesters focus on providing expecting mothers with strategies to manage common physical and emotional challenges during pregnancy. This includes information on dealing with nausea, fatigue, backaches, and emotional changes. Understanding and coping with these discomforts can help pregnant women have a more comfortable and healthy pregnancy.
A: Methods of pain relief are typically covered in childbirth preparation classes closer to the due date, not in early pregnancy classes.
B: The phases and stages of labor are usually discussed in depth in childbirth education classes taken later in pregnancy, not in early pregnancy classes.
D: Prebirth and postbirth care of a patient having a cesarean birth is a specific topic that may be covered in a separate class for women who are planning or have been recommended to have a cesarean birth, not typically in early pregnancy classes.
In 2000, the perinatal mortality rate in one county was 16. The nurse interprets that information as which of the following?
- A. 16 babies died between 28 and 40 weeks' gestation per 1,000 full-term pregnancies.
- B. 16 babies died between 28 weeks' gestation and 28 days of age per 1,000 live births.
- C. 16 babies died between birth and 1 month of life per 1,000 full-term pregnancies.
- D. 16 babies died between 1 month of life and 1 year of life per 1,000 live births.
Correct Answer: B
Rationale: The perinatal mortality rate includes deaths from 28 weeks of gestation to 28 days after birth per 1,000 live births.
The nurse is admitting a client, who reports, 'My water broke yesterday, and I haven't felt my baby move any today.' She is 38 weeks with a history of gestational diabetes. Which assessment data is of most concern to the nurse on admission?
- A. Maternal vital signs: T 100.2, HR 104, RR 20, BP 136/82
- B. Pain score 6/10
- C. Minimal variability and variable decelerations
- D. 5 cm/80% effaced/0 station
Correct Answer: C
Rationale: The correct answer is C because minimal variability and variable decelerations on fetal heart monitoring indicate fetal distress, which is a critical concern. Minimal variability suggests the baby's nervous system is compromised, and decelerations can indicate umbilical cord compression or placental insufficiency, possibly leading to fetal hypoxia. This situation requires immediate intervention to prevent potential harm to the baby.
Choice A is incorrect as the vital signs are slightly elevated but not as concerning as fetal distress. Choice B is incorrect as pain score is subjective and not as critical as fetal well-being. Choice D is incorrect as cervical dilation/effacement/station is important for labor progress but not as concerning as fetal distress in this scenario.
The nurse is performing Leopold's maneuvers on a pregnant patient at 36 weeks of gestation and determines the fetal lie is longitudinal, palpates the fetal legs in the top of the uterus, and palpates the fetal head above the symphysis pubis. Which fetal presentation does the nurse document in the EHR?
- A. cephalic
- B. compound
- C. transverse
- D. breech
Correct Answer: D
Rationale: The correct answer is D: breech. At 36 weeks of gestation, if the nurse palpates the fetal head above the symphysis pubis and the fetal legs are at the top of the uterus, it indicates a breech presentation where the baby's buttocks or feet are positioned to be delivered first. In a breech presentation, the fetal head is not engaged in the pelvis and is palpable above the symphysis pubis. The longitudinal lie with the fetal legs on top further supports the breech presentation.
Summary:
A: Cephalic presentation would have the fetal head engaged in the pelvis.
B: Compound presentation involves an additional body part alongside the presenting part.
C: Transverse lie would have the baby positioned horizontally across the uterus.
D: Breech presentation aligns with the given scenario of palpating fetal legs on top and head above the symphysis pubis.
A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception is
- A. using increased environmental stimulation as a method of distraction.
- B. restricting family and friends from visiting during the labor period to keep the patient focused on breathing techniques.
- C. medicating the patient frequently to reduce pain perception.
- D. assisting the patient in breathing methods aimed at taking control of pain perception based on the contraction pattern.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Breathing techniques help in managing pain perception during labor.
2. By assisting the patient in breathing methods, she gains control over her pain perception.
3. Controlled breathing can help distract from the intensity of contractions.
4. By focusing on breathing patterns, the patient can stay calm and manage pain effectively.
Summary:
A, B, and C are incorrect because they do not address pain management directly through breathing techniques. Option A relies on distraction, B focuses on isolation rather than coping mechanisms, and C suggests heavy reliance on medication rather than self-control.