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A nurse is caring for a laboring person who is experiencing fetal tachycardia. What is the priority intervention?
- A. administer oxygen
- B. monitor fetal heart rate
- C. increase fluid intake
- D. increase oxygen flow
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal tachycardia indicates decreased oxygen supply to the fetus. Administering oxygen helps improve oxygenation to the fetus, addressing the root cause. Monitoring fetal heart rate (B) is important but not the priority over addressing the oxygen supply. Increasing fluid intake (C) does not directly address the fetal tachycardia. Increasing oxygen flow (D) is not necessary if the person is already receiving sufficient oxygen.
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A 36-week gestation gravid lies flat on her back.
- A. Hypertension.
- B. Dizziness.
- C. Rales.
- D. Chloasma.
Correct Answer: B
Rationale: Lying flat on the back can compress the inferior vena cava, leading to reduced blood flow and dizziness. Chloasma, rales, and hypertension are unrelated to this position.
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.
The nurse is caring for a pregnant patient who has a history of gestational hypertension. Which intervention is most important to reduce the risk of complications?
- A. Monitor blood pressure regularly during pregnancy.
- B. Encourage the patient to exercise vigorously.
- C. Instruct the patient to eat a high-sodium diet.
- D. Advise the patient to reduce her fluid intake to avoid edema.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood pressure regularly during pregnancy. Regular monitoring is crucial to detect any changes in blood pressure early and intervene promptly to prevent complications like preeclampsia.
Choice B is incorrect because vigorous exercise can increase blood pressure. Choice C is incorrect as a high-sodium diet can worsen hypertension. Choice D is incorrect as reducing fluid intake can lead to dehydration and potentially exacerbate hypertension. Regular blood pressure monitoring is key in managing gestational hypertension and ensuring the best outcomes for both the mother and the baby.
A nurse is assessing a postpartum person for signs of deep vein thrombosis (DVT). What is the most common sign of DVT in the postpartum period?
- A. Swelling and redness of the calf
- B. Pain in the lower leg
- C. Heat intolerance
- D. Cold intolerance
Correct Answer: A
Rationale: The correct answer is A: Swelling and redness of the calf. Postpartum women are at a higher risk for DVT due to hormonal changes and immobility. Swelling and redness in the calf indicate possible DVT as blood clots can cause inflammation and blockage in the veins. Pain in the lower leg (B) is a common symptom but not the most specific for DVT. Heat intolerance (C) and cold intolerance (D) are not typically associated with DVT and are unrelated symptoms in this context.
A pregnant patient is at 34 weeks gestation and reports sudden sharp abdominal pain and difficulty breathing. What is the nurse's priority action?
- A. Encourage the patient to lie down and monitor the symptoms.
- B. Administer pain medication and schedule an ultrasound.
- C. Call the healthcare provider immediately and prepare for possible preterm labor.
- D. Assess the fetal heart rate and monitor for contractions.
Correct Answer: C
Rationale: The correct answer is C - Call the healthcare provider immediately and prepare for possible preterm labor. At 34 weeks gestation, sudden sharp abdominal pain and difficulty breathing could indicate a serious complication such as placental abruption or pulmonary embolism. Calling the healthcare provider ensures prompt assessment and appropriate intervention to prevent harm to the mother and baby. Encouraging the patient to lie down may delay necessary intervention. Administering pain medication before determining the cause of pain could mask important symptoms. Assessing the fetal heart rate and monitoring for contractions are important but secondary actions to calling the healthcare provider in this urgent situation.