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How would a patient who has taken Lamaze education respond when the health-care provider recommends breaking the bag of waters in early labor?
- A. As long as it will speed up my labor, that is fine.â€
- B. I trust whatever intervention you think is right.â€
- C. What are the risks and benefits of breaking my water right now?â€
- D. Will I be able to get an epidural after you break my water?â€
Correct Answer: C
Rationale: Lamaze encourages informed decision-making, prompting patients to ask about risks and benefits.
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The nurse is assessing a client at 36 weeks' gestation who reports swelling in the hands and face. What is the priority nursing action?
- A. Check the client’s blood pressure.
- B. Reassure the client that swelling is normal.
- C. Encourage the client to reduce salt intake.
- D. Evaluate the fetal heart rate.
Correct Answer: A
Rationale: Swelling in the hands and face may indicate preeclampsia, requiring immediate blood pressure assessment.
The nurse is assessing a client with suspected preeclampsia. What symptom supports this diagnosis?
- A. Hyperglycemia.
- B. Proteinuria.
- C. Increased fetal movement.
- D. Hypotension.
Correct Answer: B
Rationale: Proteinuria is a hallmark symptom of preeclampsia, along with hypertension and other systemic findings.
Positive signs of pregnancy
- A. FHR detected by electronic doppler @10-12 wks
- B. Active fetal movements palpable by examiner
- C. Outline of fetus by radiography or ultrasound
Correct Answer: B
Rationale: One of the positive signs of pregnancy is the active fetal movements palpable by the examiner. This occurs when the examiner is able to feel the movements of the fetus inside the uterus. This sign usually becomes noticeable in the second half of pregnancy and is a clear indication that the pregnancy is progressing normally. It is a reassuring sign for both the pregnant individual and the healthcare provider that the fetus is active and healthy.
How should a nurse handle a newborn with meconium-stained amniotic fluid?
- A. Suction the airway immediately after birth
- B. Monitor for signs of aspiration
- C. Encourage immediate skin-to-skin contact
- D. Administer antibiotics to the newborn immediately
Correct Answer: A
Rationale: Suctioning the airway immediately reduces the risk of aspiration and respiratory complications.
A nurse is instructing a client who is takingan oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following?
- A. Reduced menstrual flow.
- B. Breast tenderness.
- C. Shortness of breath.
- D. Headaches. Maternal exam 1 from Victoria
Correct Answer: C
Rationale: Shortness of breath is a potential danger sign that should be reported to the healthcare provider when taking oral contraceptives. It could indicate a serious side effect such as a blood clot in the lungs, also known as a pulmonary embolism, which can be a life-threatening condition. Therefore, it is important for the client to seek medical attention immediately if they experience sudden shortness of breath while on oral contraceptives. Reduced menstrual flow, breast tenderness, and headaches are common side effects of oral contraceptives and are not usually considered danger signs that require immediate medical attention.