Nokea
A pregnant patient at 30 weeks gestation reports swelling in her legs and feet. Which intervention is most appropriate for the nurse to recommend?
- A. Encourage the patient to elevate her legs and rest regularly.
- B. Increase sodium intake to help with fluid retention.
- C. Administer diuretics to reduce swelling and fluid retention.
- D. Instruct the patient to avoid drinking fluids to decrease swelling.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to elevate her legs and rest regularly. This intervention is appropriate because elevating the legs helps reduce swelling by promoting venous return and decreasing fluid accumulation in the lower extremities. Resting regularly also helps reduce the strain on the circulatory system.
Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and swelling. Choice C is incorrect because administering diuretics during pregnancy can pose risks to the fetus and should only be done under medical supervision. Choice D is incorrect because limiting fluid intake can lead to dehydration and is not recommended during pregnancy, especially when experiencing swelling.
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Which of the following is the most appropriate nursing action for a patient who has been administered an epidural block and is now experiencing hypotension?
- A. Administer a bolus of IV fluids
- B. Place the patient in a Trendelenburg position
- C. Administer oxygen via mask
- D. Raise the head of the bed slightly
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. Hypotension after an epidural block is often due to vasodilation caused by the block. Administering IV fluids can help increase blood volume and improve blood pressure. This action is crucial in maintaining perfusion to vital organs.
Choice B: Placing the patient in a Trendelenburg position can potentially worsen hypotension by increasing venous return to the heart, leading to further vasodilation and reduced blood pressure.
Choice C: Administering oxygen via mask may be important in some situations but is not the primary intervention for hypotension caused by epidural block.
Choice D: Raising the head of the bed slightly is not the best option for treating hypotension as it does not address the underlying cause of vasodilation and decreased blood pressure.
A 30-year-old pregnant patient is at 36 weeks gestation and expresses concerns about swelling in her legs. Which of the following assessments is most important for the nurse to make?
- A. Assess the patient's weight gain during the pregnancy.
- B. Examine the legs for any signs of deep vein thrombosis (DVT).
- C. Instruct the patient to elevate her legs and rest.
- D. Evaluate the patient's dietary intake of sodium.
Correct Answer: B
Rationale: The correct answer is B: Examine the legs for any signs of deep vein thrombosis (DVT). At 36 weeks gestation, pregnant women are at higher risk for DVT due to increased blood volume and pressure on the veins from the growing uterus. DVT can be life-threatening if not detected early. Assessing for any signs of DVT such as redness, warmth, swelling, or pain in the legs is crucial for prompt intervention.
Incorrect choices:
A: Assessing weight gain is important but not the priority in this situation where DVT is a concern.
C: Instructing the patient to elevate her legs and rest can help with swelling but does not address the potential serious complication of DVT.
D: Evaluating dietary intake of sodium is not the priority in this situation where DVT is a concern.
A 37-week gravid client states that she noticed a 'white liquid' leaking from her breasts during a recent shower.
- A. Advise the woman that she may have a galactocele.
- B. Encourage the woman to pump her breasts to stimulate an adequate milk supply.
- C. Assess the liquid because a breast discharge is diagnostic of a mammary infection.
- D. Reassure the mother that this is normal in the third trimester.
Correct Answer: D
Rationale: In the third trimester, colostrum production can cause a white liquid to leak from the breasts. This is a normal physiological response as the body prepares for breastfeeding.
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. What sample will be collected for the initial screening process?
- A. Urine
- B. Blood
- C. Saliva
- D. Amniotic fluid
Correct Answer: B
Rationale: AFP screening is done using a blood sample, which is less invasive than an amniocentesis.
A woman missed her menstrual period 1 week ago and has come to the doctor’s office for a pregnancy test. Which placental hormone is measured in pregnancy tests?
- A. Progesterone
- B. Estrogen
- C. Human chorionic gonadotropin
- D. Human placental lactogen
Correct Answer: C
Rationale: Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.