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What is the primary purpose of performing a vaginal examination during labor?
- A. to assess cervical dilation and effacement
- B. to assess fetal well-being and progress of labor
- C. to identify fetal distress
- D. to assess fetal descent and station
Correct Answer: B
Rationale: The correct answer is B because the primary purpose of performing a vaginal examination during labor is to assess fetal well-being and progress of labor. By conducting a vaginal exam, healthcare providers can monitor the fetal heart rate, position, and stage of labor. This information helps determine if the labor is progressing normally and if any interventions are needed. Choice A is incorrect because cervical dilation and effacement can be assessed but are not the primary purpose. Choice C is incorrect as fetal distress is typically identified through other methods such as continuous fetal monitoring. Choice D is incorrect as assessing fetal descent and station can be done through vaginal examination but is not the primary purpose.
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A nurse is caring for a laboring person who is in the third stage of labor. What is the most appropriate nursing intervention during this stage?
- A. assist with the delivery of the placenta
- B. prepare for a vaginal birth
- C. administer oxytocin
- D. apply gentle pressure to the uterus
Correct Answer: A
Rationale: The correct answer is A: assist with the delivery of the placenta. During the third stage of labor, the placenta needs to be delivered. This is done by gently applying traction to the umbilical cord while supporting the uterus to facilitate the expulsion of the placenta. This step is crucial to prevent postpartum hemorrhage.
Choice B (prepare for a vaginal birth) is incorrect because the person is already in the third stage of labor, which means the baby has been delivered and they are now focusing on delivering the placenta.
Choice C (administer oxytocin) is incorrect because while oxytocin may be used to help control bleeding after the placenta is delivered, it is not the most appropriate intervention during the third stage of labor.
Choice D (apply gentle pressure to the uterus) is incorrect because direct pressure to the uterus is not the primary intervention during the third stage of labor; assisting with the delivery of the placenta takes precedence.
A nurse is assessing a pregnant patient at 36 weeks gestation who complains of pain in the lower abdomen and back. The nurse finds no signs of labor. Which of the following interventions should the nurse implement?
- A. Encourage the patient to rest and monitor for any changes in symptoms.
- B. Administer pain medication and schedule an appointment with the doctor.
- C. Perform a pelvic exam to determine the cause of the pain.
- D. Instruct the patient to remain in bed for the rest of the day.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to rest and monitor for any changes in symptoms. At 36 weeks gestation, the patient might be experiencing Braxton Hicks contractions or round ligament pain, which are common in late pregnancy. Encouraging rest allows for potential relief of discomfort. Monitoring for any changes in symptoms is essential to rule out preterm labor. Option B is incorrect as administering pain medication without identifying the cause may mask symptoms of preterm labor. Option C is incorrect as performing a pelvic exam could potentially cause harm if the patient is experiencing preterm labor. Option D is incorrect as prolonged bed rest is not recommended in pregnancy and may not alleviate the pain or address the underlying cause.
A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits?
- A. Leg cramps.
- B. Varicose veins.
- C. Hemorrhoids.
- D. Fainting spells.
Correct Answer: A
Rationale: Leg cramps, varicose veins, and hemorrhoids are common complaints during pregnancy due to increased blood volume and pressure on the lower extremities. Fainting spells are not considered normal and may indicate an underlying issue.
A 40-week pregnant woman is admitted to the labor and delivery unit and is in active labor. Her cervix is 8 cm dilated, and she is experiencing strong contractions. What is the next priority action?
- A. Administer an epidural block
- B. Perform a vaginal examination to assess fetal descent
- C. Assess the fetal heart rate
- D. Prepare for delivery
Correct Answer: C
Rationale: The correct answer is C: Assess the fetal heart rate. This is the next priority action because monitoring the fetal heart rate is crucial to ensure the well-being of the baby during labor. It helps in identifying any signs of fetal distress and guides the healthcare provider in making timely interventions to prevent complications. Administering an epidural block (choice A) can be considered later once the fetal well-being is ensured. Performing a vaginal examination (choice B) may not be necessary at this moment as the woman is already in active labor and has progressed to 8 cm dilation. Preparing for delivery (choice D) should only be done after assessing the fetal well-being to ensure a safe delivery.
A pregnant patient is at 24 weeks gestation and reports occasional cramping and lower abdominal discomfort. What should the nurse do first?
- A. Assess for signs of preterm labor and monitor the patient for regular contractions.
- B. Administer pain medications and encourage the patient to rest.
- C. Perform a pelvic exam to assess for cervical changes.
- D. Instruct the patient to increase fluid intake and monitor the symptoms.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of preterm labor and monitor the patient for regular contractions. This is the most appropriate action as the patient is experiencing cramping and lower abdominal discomfort, which could indicate preterm labor. Step 1: Assessing for signs of preterm labor, such as regular contractions, is crucial to determine the patient's condition. Step 2: Monitoring the patient for regular contractions helps in identifying any patterns and assessing the progression of labor. Other choices are incorrect as B: Administering pain medications without assessing for preterm labor can mask important indicators. C: Performing a pelvic exam may increase the risk of infection and is not the priority. D: Instructing the patient to increase fluid intake may not address the potential risk of preterm labor.