Nokea
A 22-year-old woman presents to the labor and delivery unit in labor at 39 weeks gestation. Her cervix is 6 cm dilated and 100% effaced. What should the nurse do next?
- A. Prepare for delivery
- B. Administer pain relief medications
- C. Continue to monitor contractions and fetal heart rate
- D. Perform a vaginal examination to check for fetal descent
Correct Answer: C
Rationale: The correct answer is C: Continue to monitor contractions and fetal heart rate. At 6 cm dilated and 100% effaced, the woman is in active labor, but delivery is not imminent. Monitoring contractions and fetal heart rate is crucial to ensure the progress of labor and fetal well-being. This step allows the nurse to assess for any signs of fetal distress or labor progression. Administering pain relief medications (B) can be considered based on the woman's pain level, but it is not the immediate priority. Preparing for delivery (A) is premature at this stage. Performing a vaginal examination (D) may not be necessary unless there are concerns about fetal descent or progress of labor.
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A pregnant woman must have a glucose challenge test (GCT). Which of the following should be included in the preprocedure teaching?
- A. Fast for 12 hours before the test.
- B. Bring a urine specimen to the laboratory on the day of the test.
- C. Be prepared to have 4 blood specimens taken on the day of the test.
- D. The test should take one hour to complete.
Correct Answer: D
Rationale: The glucose challenge test typically takes one hour to complete and does not require fasting or multiple blood specimens. A urine specimen is not required for this test.
A woman in labor is receiving magnesium sulfate for preterm labor. What should the nurse monitor closely during this treatment?
- A. Deep tendon reflexes
- B. Respiratory rate
- C. Maternal blood pressure
- D. Fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes. Magnesium sulfate can cause muscle weakness and respiratory depression due to its effect on the central nervous system. Monitoring deep tendon reflexes helps assess for magnesium toxicity. Respiratory rate (B) should also be monitored, but it is not the most critical parameter for magnesium sulfate. Maternal blood pressure (C) is important, but changes are usually gradual and not directly related to magnesium sulfate. Fetal heart rate (D) is crucial, but in this case, the focus should be on the mother's response to the medication.
The nurse is educating a pregnant patient on the importance of maintaining a balanced diet during pregnancy. Which of the following statements by the patient indicates effective teaching?
- A. I should avoid all carbohydrates to prevent gestational diabetes.
- B. I need to eat extra food for my baby to ensure proper growth.
- C. I will eat a variety of nutrient-dense foods and avoid processed foods.
- D. I can focus on eating as much protein as possible to support my baby's development.
Correct Answer: C
Rationale: Rationale: Choice C is correct because it emphasizes the importance of eating a variety of nutrient-dense foods and avoiding processed foods. This approach ensures the pregnant patient receives essential nutrients for her health and the baby's development. Variety helps cover all necessary nutrients, while avoiding processed foods reduces the intake of unhealthy additives. This balanced diet promotes optimal health outcomes for both the mother and the baby.
Summary of Incorrect Choices:
A: Avoiding all carbohydrates is not recommended as they are a vital energy source and cutting them out completely can lead to nutritional deficiencies.
B: Eating extra food indiscriminately can result in excessive weight gain and complications. The focus should be on nutrient-dense foods, not just quantity.
D: Focusing solely on protein neglects other important nutrients needed during pregnancy. A well-rounded diet is essential for overall health.
A nurse is caring for a pregnant patient who is 28 weeks gestation and has been diagnosed with gestational diabetes. What is the nurse's priority teaching for this patient?
- A. Encourage the patient to exercise vigorously to manage blood sugar levels.
- B. Monitor blood glucose levels regularly and follow a balanced diet.
- C. Instruct the patient to limit fluid intake to prevent complications.
- D. Recommend insulin therapy immediately to control blood sugar levels.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose levels regularly and follow a balanced diet. This is the priority teaching for a pregnant patient with gestational diabetes because it focuses on managing blood sugar levels effectively. Regular monitoring helps the patient understand how their body responds to different foods and activities. Following a balanced diet helps maintain stable blood sugar levels and provides essential nutrients for the baby's development.
A: Encouraging vigorous exercise may not be safe during pregnancy, especially for a patient with gestational diabetes.
C: Limiting fluid intake is not a priority teaching for gestational diabetes and may lead to dehydration, which can be harmful during pregnancy.
D: Recommending insulin therapy immediately is not the first-line treatment for gestational diabetes. Lifestyle modifications like diet and exercise are usually tried first.
The nurse is caring for a pregnant patient who is 24 weeks gestation and reports nausea, vomiting, and weight loss. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to eat a high-protein diet and avoid fluids during meals.
- B. Encourage the patient to rest and avoid any exercise.
- C. Assess the patient's hydration status and notify the healthcare provider if necessary.
- D. Recommend over-the-counter anti-nausea medications to control symptoms.
Correct Answer: C
Rationale: The correct answer is C: Assess the patient's hydration status and notify the healthcare provider if necessary.
Rationale:
1. Nausea, vomiting, and weight loss in pregnancy may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances.
2. Assessing hydration status is crucial to determine the severity of the condition and guide appropriate interventions.
3. Notifying the healthcare provider allows for further evaluation, possible treatment adjustments, and monitoring to prevent complications.
Summary:
A: Instructing the patient to eat a high-protein diet and avoid fluids during meals does not address the immediate concern of dehydration and may worsen symptoms.
B: Encouraging the patient to rest and avoid exercise is important but does not address the primary issue of dehydration.
D: Recommending over-the-counter anti-nausea medications may provide symptomatic relief but does not address the underlying cause or hydration status.