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A 32-week pregnant woman is admitted to the hospital in preterm labor. What is the most appropriate intervention to delay delivery?
- A. Administer corticosteroids to promote fetal lung development
- B. Provide an epidural for pain management
- C. Give magnesium sulfate to inhibit uterine contractions
- D. Begin oxytocin infusion to speed up labor
Correct Answer: C
Rationale: The correct answer is C: Give magnesium sulfate to inhibit uterine contractions. Magnesium sulfate is used to delay preterm labor by relaxing the uterine muscles, thus decreasing contractions. This intervention helps to delay delivery and give time for other interventions to be implemented, such as administering corticosteroids to promote fetal lung development. Providing an epidural for pain management (B) does not address the issue of preterm labor. Beginning oxytocin infusion (D) would speed up labor, which is not appropriate in this scenario. Administering corticosteroids (A) is a beneficial intervention but should be done after delaying delivery with magnesium sulfate.
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The nurse is caring for a pregnant patient who is 30 weeks gestation and reports feeling faint and lightheaded. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to lie on her back to improve circulation.
- B. Encourage the patient to take deep breaths and sit down immediately.
- C. Instruct the patient to stand up slowly and rest for 10 minutes.
- D. Ask the patient to eat something sweet to raise her blood sugar.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to take deep breaths and sit down immediately. This action is appropriate because the patient is experiencing symptoms of hypotension, which can lead to decreased blood flow to the brain causing faintness and lightheadedness. By encouraging the patient to take deep breaths and sit down immediately, the nurse is helping to increase oxygen intake and improve circulation, which can alleviate the symptoms.
Explanation for why the other choices are incorrect:
A: Instructing the patient to lie on her back can actually worsen symptoms as it can lead to a decrease in blood flow to the brain.
C: Instructing the patient to stand up slowly is not appropriate as the patient is already feeling faint and lightheaded. This can increase the risk of falling and injury.
D: Asking the patient to eat something sweet may not address the underlying cause of the symptoms, which is likely related to hypotension. It is important to address the immediate
A nurse is monitoring a postpartum person for signs of infection. Which finding would be most concerning in the first 24 hours after delivery?
- A. fever
- B. foul-smelling lochia
- C. increased blood pressure
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: fever. A fever in the first 24 hours after delivery is most concerning as it may indicate an infection, such as endometritis, which can lead to serious complications if not promptly treated. Postpartum fever is often the earliest sign of infection due to retained products of conception or ascending genital tract infection. Monitoring for fever is crucial as it can help prevent sepsis. Foul-smelling lochia (choice B) may suggest infection but is not as immediate a concern as fever. Increased blood pressure (choice C) and heart rate (choice D) may be normal physiological responses to delivery and are not specific indicators of infection in the immediate postpartum period.
A pregnant patient at 32 weeks gestation reports increased pressure in the pelvic area and mild cramping. What should the nurse assess first?
- A. The fetal heart rate and signs of labor.
- B. The patient's blood pressure and urine for protein.
- C. The presence of vaginal discharge or bleeding.
- D. The patient's dietary intake and hydration status.
Correct Answer: A
Rationale: The correct answer is A: The fetal heart rate and signs of labor. At 32 weeks gestation, any pelvic pressure and cramping could be indicative of preterm labor, which is a critical concern. Assessing the fetal heart rate can help determine fetal well-being and signs of distress. Monitoring for signs of labor such as contractions, cervical changes, and rupture of membranes is essential for timely intervention.
Choice B: Assessing blood pressure and urine for protein is important in monitoring for preeclampsia, but it is not the priority in this case where signs of preterm labor are reported.
Choice C: Vaginal discharge or bleeding could indicate various conditions, but in this scenario, the focus should be on ruling out preterm labor first.
Choice D: Dietary intake and hydration status are important aspects of prenatal care, but they are not the priority when assessing a pregnant patient reporting pelvic pressure and cramping at 32 weeks gestation.
What is the priority nursing action when a postpartum person experiences a boggy uterus after delivery?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. administer an analgesic
- D. administer pain medication
Correct Answer: B
Rationale: The correct answer is B: administer a uterotonic medication. This is the priority nursing action because a boggy uterus indicates uterine atony, which can lead to postpartum hemorrhage. Uterotonic medications help the uterus contract and reduce bleeding. Performing fundal massage (A) can be done after administering the medication to aid in uterine contraction. Administering an analgesic (C) or pain medication (D) is not the priority as the main concern is preventing excessive bleeding.
A nurse is educating a birthing person about the signs and symptoms of postpartum hemorrhage. Which of the following is an early sign of postpartum hemorrhage?
- A. bright red bleeding
- B. increased blood pressure
- C. severe abdominal pain
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: bright red bleeding. This is an early sign of postpartum hemorrhage because it indicates active bleeding from the uterus. Bright red blood suggests fresh bleeding, which is more concerning than darker blood. Increased blood pressure (B) is not typically associated with postpartum hemorrhage. Severe abdominal pain (C) is more indicative of other complications like uterine rupture. Increased heart rate (D) can be a sign of postpartum hemorrhage, but bright red bleeding is a more specific early indicator.