Nokea
What procedure might the nurse perform to determine the presentation of the fetus?
- A. vaginal exam
- B. ultrasound
- C. palpation of contractions
- D. laboring person interview
Correct Answer: B
Rationale: The correct answer is B: ultrasound. Ultrasound is the most accurate and non-invasive method to determine the presentation of the fetus by visualizing the position of the baby in the womb. It allows the nurse to see if the fetus is in a cephalic (head-down) or breech (feet or buttocks down) position. This information is crucial for assessing the progress of labor and planning appropriate interventions.
A: Vaginal exam is not typically used to determine fetal presentation as it does not provide a clear view of the baby's position.
C: Palpation of contractions helps assess the strength and frequency of contractions but does not directly determine fetal presentation.
D: Laboring person interview may provide valuable information about symptoms and history but does not offer direct insight into fetal presentation.
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A nurse is assessing a 36-week pregnant patient who is complaining of sudden and severe headaches. What is the nurse's priority action?
- A. Encourage the patient to take a warm shower and rest.
- B. Assess the patient's blood pressure and check for signs of preeclampsia.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to drink more water to stay hydrated.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's blood pressure and check for signs of preeclampsia. Sudden and severe headaches in a pregnant patient could indicate preeclampsia, a serious condition characterized by high blood pressure. The nurse's priority is to assess for signs of preeclampsia to ensure the safety of both the mother and the baby. Encouraging rest or a warm shower, administering pain medication, or advising hydration do not address the potential underlying issue of preeclampsia and could delay necessary medical intervention.
A nurse is caring for a laboring person who is experiencing strong contractions. What is the most important intervention to support the laboring person during this time?
- A. provide comfort measures
- B. assist with breathing exercises
- C. provide reassurance and comfort
- D. administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: provide comfort measures. Comfort measures such as massage, positioning, and relaxation techniques help the laboring person cope with the pain and intensity of contractions. By providing comfort, the nurse can help reduce stress and anxiety, promoting a more positive labor experience.
Choice B (assist with breathing exercises) can be helpful, but comfort measures are more essential for overall well-being during labor. Choice C (provide reassurance and comfort) is similar to the correct answer but lacks the specific action of providing comfort measures. Choice D (administer antibiotics) is irrelevant to the management of strong contractions and is not indicated unless there is a specific medical reason for antibiotics.
A nurse is preparing a postpartum person for discharge after a vaginal birth. What is the most important aspect of discharge teaching?
- A. offer emotional support
- B. assist with breastfeeding immediately
- C. assist with positioning the person
- D. provide non-pharmacological pain relief
Correct Answer: A
Rationale: The correct answer is A: offer emotional support. This is crucial as postpartum can be a challenging time emotionally. Providing emotional support helps the person cope with any feelings of anxiety, sadness, or overwhelm. Breastfeeding (B) and positioning assistance (C) are important but not the most critical aspect of discharge teaching. Non-pharmacological pain relief (D) is important but not as crucial as emotional support for overall well-being.
A pregnant woman who is 24 weeks gestation is experiencing excessive vomiting and dehydration. Which of the following interventions should the nurse prioritize?
- A. Administer an antiemetic to control vomiting.
- B. Encourage the patient to rest and avoid moving too much.
- C. Start intravenous fluids to restore hydration and electrolytes.
- D. Recommend that the patient eat smaller, more frequent meals.
Correct Answer: C
Rationale: The correct answer is C, starting intravenous fluids to restore hydration and electrolytes. This is the priority intervention because dehydration during pregnancy can lead to serious complications for both the mother and the baby. By administering IV fluids, the nurse can quickly rehydrate the mother and replenish electrolytes to ensure the well-being of both.
Choice A (Administer an antiemetic) may help control vomiting, but addressing dehydration is the primary concern. Choice B (Encourage rest) is important, but without addressing hydration first, rest alone will not resolve the issue. Choice D (Recommend smaller meals) may be helpful in managing nausea, but it does not address the immediate need for hydration and electrolyte balance.
A nurse is caring for a postpartum person who is breastfeeding. What is the most important factor for successful breastfeeding?
- A. frequent breastfeeding
- B. proper positioning
- C. supportive communication
- D. promote rest and hydration
Correct Answer: B
Rationale: The correct answer is B: proper positioning. Proper positioning is crucial for successful breastfeeding as it ensures the baby latches on effectively, leading to efficient milk transfer and preventing nipple pain or damage. Incorrect answers:
A: frequent breastfeeding - While important, proper positioning is more critical for successful breastfeeding.
C: supportive communication - While important for overall well-being, it is not the most crucial factor for successful breastfeeding.
D: promote rest and hydration - While important for the postpartum person's health, proper positioning is key for successful breastfeeding.