Nokea
A 20-year-old client states that the at-home pregnancy test that she took this morning was positive. Which of the following comments by the nurse is appropriate at this time?
- A. Congratulations, you and your family must be so happy.
- B. Have you told the baby’s father yet?
- C. How do you feel about the results?
- D. Please tell me when your last menstrual period was.
Correct Answer: C
Rationale: It is important to assess the client's emotional response to the pregnancy test result before providing further guidance or congratulations.
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A nurse is caring for a pregnant patient who is 12 weeks gestation and reports feeling fatigued. Which of the following is the nurse's most appropriate response?
- A. Fatigue is normal during the first trimester and should improve in the second trimester.
- B. You should rest as much as possible, but try to get up and move regularly to prevent complications.
- C. Fatigue may indicate an underlying medical condition and should be investigated immediately.
- D. I will prescribe iron supplements to help with your fatigue.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Fatigue is common in the first trimester due to hormonal changes and increased energy demands.
2. Second trimester typically brings relief as hormone levels stabilize and energy levels increase.
3. Reassuring the patient about the normalcy of fatigue promotes understanding and reduces anxiety.
Summary:
- Choice B focuses on rest but does not address the normalcy of fatigue in the first trimester.
- Choice C jumps to conclusions without considering common causes first.
- Choice D assumes iron deficiency without assessing the patient's overall health status.
Where is the usual location for implantation of the zygote?
- A. Upper section of the posterior uterine wall
- B. Lower portion of the uterus near the cervical os
- C. Inner third of the fallopian tube near the uterus
- D. Lateral aspect of the uterine wall
Correct Answer: A
Rationale: The zygote usually implants in the upper section of the posterior uterine wall.
The woman's partner is lightly stroking her abdomen as an alternative to medication for pain relief in labor. What is this known as?
- A. Counterpressure
- B. Effieurage
- C. Guided imagery
- D. Biofeedback
Correct Answer: A
Rationale: The correct answer is A: Counterpressure. This technique involves applying pressure to specific areas to alleviate pain during labor. In this scenario, the partner is using light strokes on the woman's abdomen to provide pain relief. Counterpressure helps release endorphins, which are natural painkillers, and distracts the brain from focusing on the pain sensations. Effleurage (B) is a gentle stroking technique used for relaxation, not specifically for pain relief. Guided imagery (C) involves visualizing calming scenes to reduce stress, not directly addressing pain. Biofeedback (D) is a method of monitoring and controlling physiological responses, not a hands-on pain relief technique like counterpressure.
A pregnant patient is at 34 weeks gestation and reports persistent lower back pain and difficulty sleeping. What is the nurse's best recommendation for this patient?
- A. Rest in bed and avoid any physical activity.
- B. Use a firm mattress and avoid sleeping on the back.
- C. Take over-the-counter pain medications to alleviate symptoms.
- D. Apply heat to the back and practice good posture while sitting.
Correct Answer: B
Rationale: The correct answer is B: Use a firm mattress and avoid sleeping on the back. This recommendation is appropriate because during pregnancy, the weight of the uterus can compress blood vessels when lying on the back, causing back pain and affecting circulation. Using a firm mattress can provide better support for the back, relieving discomfort. Avoiding sleeping on the back reduces the risk of decreased blood flow to the fetus.
A: Rest in bed and avoid any physical activity is incorrect because it can lead to muscle stiffness and worsen back pain.
C: Taking over-the-counter pain medications may provide temporary relief but does not address the root cause of the discomfort.
D: Applying heat to the back and practicing good posture are helpful strategies, but avoiding sleeping on the back is more crucial to alleviate the symptoms in this case.
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?
- A. Hemophilia
- B. Sickle cell anemia
- C. A neural tube defect
- D. Abnormal lecithin-to-sphingomyelin ratio
Correct Answer: C
Rationale: An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter maternal serum, indicating a neural tube defect.