Nokea
What is the priority nursing action when a postpartum person experiences a boggy uterus after delivery?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. administer an analgesic
- D. administer pain medication
Correct Answer: B
Rationale: The correct answer is B: administer a uterotonic medication. This is the priority nursing action because a boggy uterus indicates uterine atony, which can lead to postpartum hemorrhage. Uterotonic medications help the uterus contract and reduce bleeding. Performing fundal massage (A) can be done after administering the medication to aid in uterine contraction. Administering an analgesic (C) or pain medication (D) is not the priority as the main concern is preventing excessive bleeding.
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A woman in labor begins to experience severe lower abdominal pain and is found to have a ruptured uterus. What is the first intervention the nurse should perform?
- A. Administer intravenous fluids
- B. Prepare the patient for immediate surgery
- C. Perform a vaginal examination
- D. Administer pain relief medications
Correct Answer: B
Rationale: The correct answer is B: Prepare the patient for immediate surgery. In the case of a ruptured uterus, prompt surgical intervention is crucial to control bleeding, repair the uterus, and prevent further complications such as hemorrhage and infection. Performing surgery is the priority over other interventions like administering fluids, pain relief medications, or performing a vaginal examination, as these actions do not address the immediate life-threatening situation of uterine rupture. Administering IV fluids may be necessary during surgery, and pain relief can be addressed post-operatively. Vaginal examination is contraindicated in cases of suspected uterine rupture as it can exacerbate the bleeding and worsen the condition.
A nurse is preparing a laboring person for a cesarean birth. What is the most important intervention before the procedure?
- A. administer preoperative medication
- B. monitor vital signs
- C. ensure proper incision care
- D. perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A because administering preoperative medication is crucial to ensure the patient's comfort and safety during the cesarean birth. Preoperative medications help reduce anxiety, prevent infection, and manage pain. Monitoring vital signs (choice B) is important but not the most critical intervention before the procedure. Ensuring proper incision care (choice C) is postoperative, not preoperative. Performing a vaginal exam (choice D) is unnecessary and potentially harmful before a cesarean birth.
A pregnant patient who is 18 weeks gestation reports that she has not felt her baby move for several hours. What should the nurse instruct the patient to do?
- A. Drink a cold beverage and lie down to count fetal movements.
- B. Wait until the morning and report any continued lack of movement to your doctor.
- C. Rest and refrain from worrying, as it is common for fetal movements to decrease.
- D. Call your doctor immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A because decreased fetal movement could indicate a potential problem. Drinking a cold beverage and lying down can stimulate the baby to move, allowing the patient to count fetal movements. This can help assess the baby's well-being. Choice B is incorrect as waiting can delay necessary intervention. Choice C is incorrect as decreased fetal movement should not be dismissed without assessment. Choice D is incorrect as immediate action is needed but calling the doctor alone may not provide immediate relief or guidance.
A nurse is educating a pregnant patient about signs of labor. Which of the following statements by the patient indicates a need for further teaching?
- A. I should be concerned if I have regular contractions every 10 minutes.
- B. If I notice a bloody show, I should call my healthcare provider.
- C. The loss of my mucous plug means that labor is starting right away.
- D. If I experience my water breaking, I should go to the hospital immediately.
Correct Answer: C
Rationale: The correct answer is C. The loss of the mucous plug does not necessarily indicate that labor is starting right away. It can happen days to weeks before labor begins. A: Regular contractions every 10 minutes suggest labor progression. B: A bloody show can indicate the onset of labor. D: Water breaking is a sign of labor and requires immediate medical attention. Therefore, the patient needs further teaching on the timing and significance of losing the mucous plug.
What is the most common cause of shoulder dystocia during delivery?
- A. fetal macrosomia
- B. maternal obesity
- C. maternal diabetes
- D. advanced maternal age
Correct Answer: A
Rationale: The correct answer is A: fetal macrosomia. Fetal macrosomia, defined as a birth weight above 4 kg, is the most common cause of shoulder dystocia during delivery. This occurs when the baby's shoulders get stuck behind the mother's pelvic bone, leading to complications. Macrosomia is more likely in pregnancies with gestational diabetes, maternal obesity, and advanced maternal age, but the primary risk factor for shoulder dystocia is fetal macrosomia due to the large size of the baby. Maternal obesity, diabetes, and advanced age are secondary risk factors that can contribute to the likelihood of shoulder dystocia but are not the primary cause.