Which of the following skin changes should the nurse highlight for a pregnant woman’s health care practitioner?
- A. Linea nigra.
- B. Melasma.
- C. Petechiae.
- D. Spider nevi.
Correct Answer: C
Rationale: Petechiae (small hemorrhages under the skin) could indicate underlying medical conditions such as thrombocytopenia or coagulopathy, warranting further investigation. Linea nigra and melasma are common benign changes, while spider nevi are usually harmless but less urgent.
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A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
A nurse is caring for a postpartum person who is experiencing difficulty with breastfeeding. What is the most appropriate intervention?
- A. assist with latching
- B. provide skin-to-skin contact
- C. educate the person on breast care
- D. educate the person on postpartum care
Correct Answer: B
Rationale: The correct answer is B: provide skin-to-skin contact. This is the most appropriate intervention because it promotes bonding, regulates the baby's temperature, and enhances breastfeeding success by stimulating the baby's natural instincts. Assisting with latching (choice A) may be necessary but providing skin-to-skin contact should be prioritized. Educating on breast care (choice C) and postpartum care (choice D) are important, but the immediate need is to establish successful breastfeeding through skin-to-skin contact.
The nurse is interviewing a 38-week gestation Muslim woman.
- A. Do you plan to breastfeed your baby?
- B. What do you plan to name the baby?
- C. Which pediatrician do you plan to use?
- D. How do you feel about having an episiotomy?
Correct Answer: D
Rationale: Questions about episiotomy might be culturally sensitive or inappropriate without prior discussion of preferences, especially in certain cultural contexts like Islam.
A 36-week gestation gravid client is complaining of dyspnea when lying flat.
- A. Maternal hypertension.
- B. Fundal height.
- C. Hydramnios.
- D. Congestive heart failure.
Correct Answer: B
Rationale: As the uterus grows, the fundal height increases, which can press on the diaphragm and lead to shortness of breath when lying flat.
An 18-week gestation client telephones the obstetrician’s office stating, 'I’m really scared. I think I have breast cancer. My breasts are filled with tumors.' The nurse should base the response on which of the following?
- A. Breast cancer is often triggered by pregnancy.
- B. Nodular breast tissue is normal during pregnancy.
- C. The woman is exhibiting signs of a psychotic break.
- D. Anxiety attacks are especially common in the second trimester.
Correct Answer: B
Rationale: Nodular breast tissue is a normal change during pregnancy due to hormonal fluctuations. Breast cancer is not typically triggered by pregnancy, and anxiety attacks are not specifically common in the second trimester.