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A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?
- A. Perform a vaginal exam to assess for fetal position
- B. Prepare the patient for delivery
- C. Administer an epidural block
- D. Continue to monitor contractions and fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.
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Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
- A. Biophysical profile
- B. Multiple-marker screening
- C. Lecithin-to-sphingomyelin ratio
- D. Blood type and crossmatch of maternal and fetal serum
Correct Answer: B
Rationale: Multiple-marker screening analyzes maternal serum for abnormal levels of AFP, hCG, inhibin A, and estriol to detect chromosomal defects.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
- A. Magnesium sulfate
- B. Prostaglandin suppository
- C. RhoGAM if the patient is Rh-negative
- D. Betamethasone
Correct Answer: C
Rationale: Rh-negative women undergoing CVS require RhoGAM to prevent Rh sensitization.
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
- A. Determine if a metabolic disorder exists.
- B. Identify the sex of the fetus.
- C. Identify abnormal fetal cells.
- D. Determine fetal lung maturity.
Correct Answer: D
Rationale: At 34 weeks, amniocentesis is primarily used to assess fetal lung maturity, which is critical if early delivery is being considered.
A pregnant patient is at 24 weeks gestation and reports feeling fatigued and weak. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to rest and avoid physical activity.
- B. Assess the patient's hemoglobin and hematocrit levels to check for anemia.
- C. Recommend that the patient eat a high-calorie diet to increase energy.
- D. Encourage the patient to perform regular exercise to combat fatigue.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's hemoglobin and hematocrit levels to check for anemia. Fatigue and weakness in pregnancy can be symptoms of anemia, a common condition due to increased blood volume demands. By checking hemoglobin and hematocrit levels, the nurse can confirm or rule out anemia as the cause. Resting alone may not address the underlying issue, and high-calorie diet or regular exercise may not be appropriate if anemia is present. It is crucial to identify the root cause to provide the most effective intervention.
A nurse is caring for a postpartum person who is breastfeeding. What is the most important action to promote effective breastfeeding?
- A. assist with positioning
- B. administer analgesics
- C. administer IV fluids
- D. assist with breastfeeding positioning
Correct Answer: B
Rationale: The correct answer is B: administer analgesics. Pain management is crucial to promote effective breastfeeding as it can help the postpartum person be more comfortable and relaxed during breastfeeding sessions. This can lead to better latch and milk transfer, ultimately enhancing the breastfeeding experience.
A: assist with positioning - While positioning is important for successful breastfeeding, it is not the most crucial action compared to pain management.
C: administer IV fluids - IV fluids are not directly related to promoting effective breastfeeding. Hydration is important but not the most critical factor in this scenario.
D: assist with breastfeeding positioning - This choice is similar to option A and while important, it is not as critical as ensuring proper pain management for effective breastfeeding.