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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.
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The nurse is assessing a pregnant patient who is 30 weeks gestation and reports pain in the lower abdomen and back. What should the nurse do first?
- A. Assess for signs of preterm labor, including regular contractions.
- B. Administer pain medication and advise the patient to rest.
- C. Encourage the patient to perform light physical activity to relieve the pain.
- D. Instruct the patient to lie flat on her back and monitor the symptoms.
Correct Answer: A
Rationale: The correct answer is A because pain in the lower abdomen and back could indicate preterm labor at 30 weeks gestation. The first step is to assess for signs of preterm labor, such as regular contractions, to determine the urgency of the situation. Administering pain medication (B) without assessing the cause can mask symptoms. Encouraging physical activity (C) may worsen preterm labor. Instructing the patient to lie flat on her back (D) can decrease blood flow to the uterus and is not recommended in late pregnancy.
A patient in labor is experiencing vaginal bleeding with no pain. What is the most likely cause?
- A. Placental abruption
- B. Placenta previa
- C. Uterine rupture
- D. Cervical laceration
Correct Answer: B
Rationale: The correct answer is B: Placenta previa. In placenta previa, the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. Placental abruption (choice A) presents with painful bleeding. Uterine rupture (choice C) typically causes severe abdominal pain. Cervical laceration (choice D) usually occurs during delivery and is not typically associated with painless bleeding during labor. Placenta previa is the most likely cause in this scenario due to painless bleeding and the absence of contractions.
A nurse is educating a pregnant patient about warning signs to report during pregnancy. Which of the following statements indicates that the teaching has been effective?
- A. I should report any sudden increase in swelling, especially in my hands and face.
- B. I should wait until after my due date to report any concerns.
- C. I should only report changes in fetal movement after the third trimester.
- D. I don't need to report headaches or blurry vision unless they are severe.
Correct Answer: A
Rationale: The correct answer is A because sudden increase in swelling, especially in hands and face, can indicate preeclampsia, a serious condition during pregnancy. Swelling in these areas can be a sign of fluid retention and increased blood pressure. Prompt reporting and intervention are crucial to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because:
B: Waiting until after the due date to report concerns can lead to missed opportunities for early intervention and can be dangerous for both the mother and the baby.
C: Changes in fetal movement should be reported immediately, not just after the third trimester, as they can indicate fetal distress.
D: Headaches and blurry vision, even if not severe, can be symptoms of preeclampsia or other serious conditions that require immediate attention. Waiting for symptoms to worsen can be harmful.
A woman, 6 weeks pregnant, is having a vaginal examination. Which of the following would the practitioner expect to find?
- A. Thin cervical muscle.
- B. An enlarged ovary.
- C. Thick cervical mucus.
- D. Pale pink vaginal wall.
Correct Answer: B
Rationale: An enlarged ovary is a common finding in early pregnancy due to the corpus luteum. Thin cervical muscle, thick cervical mucus, and a pale pink vaginal wall are not typical findings at this stage.
A 38-week pregnant patient in active labor is experiencing frequent and painful contractions. What is the most appropriate action for the nurse?
- A. Administer narcotic analgesics for pain relief
- B. Provide emotional support and reassurance
- C. Assess the fetal heart rate and contraction patterns
- D. Prepare for delivery
Correct Answer: D
Rationale: The correct answer is D: Prepare for delivery. At 38 weeks of gestation and in active labor, the most appropriate action is to prepare for delivery as the patient is likely to be close to giving birth. This involves ensuring that all necessary equipment and supplies are ready, notifying the healthcare team, and positioning the patient for delivery. Administering narcotic analgesics (choice A) may not be ideal at this stage as the priority is the imminent delivery. While emotional support and reassurance (choice B) are important, they should be provided alongside preparing for delivery. Assessing the fetal heart rate and contraction patterns (choice C) is crucial but should be done concurrently with preparing for delivery to ensure the safety of both the mother and baby.