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A 37-week gravid client states that she noticed a 'white liquid' leaking from her breasts during a recent shower.
- A. Advise the woman that she may have a galactocele.
- B. Encourage the woman to pump her breasts to stimulate an adequate milk supply.
- C. Assess the liquid because a breast discharge is diagnostic of a mammary infection.
- D. Reassure the mother that this is normal in the third trimester.
Correct Answer: D
Rationale: In the third trimester, colostrum production can cause a white liquid to leak from the breasts. This is a normal physiological response as the body prepares for breastfeeding.
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A pregnant patient at 32 weeks gestation is concerned about gestational diabetes. What is the nurse's priority intervention?
- A. Encourage the patient to eat smaller, more frequent meals and monitor blood glucose levels.
- B. Administer insulin as prescribed to control blood glucose levels.
- C. Recommend a high-protein, low-carbohydrate diet to prevent blood sugar spikes.
- D. Instruct the patient to limit fluid intake to reduce blood sugar fluctuations.
Correct Answer: A
Rationale: The correct answer is A because it addresses the immediate concern of managing blood glucose levels in a pregnant patient with gestational diabetes. Encouraging smaller, more frequent meals helps stabilize blood sugar levels and prevent spikes. Monitoring blood glucose levels is crucial for timely interventions. Administering insulin (B) may be necessary but not the priority. A high-protein, low-carb diet (C) is not typically recommended for gestational diabetes. Limiting fluid intake (D) is not appropriate as hydration is important during pregnancy. In summary, choice A is the priority as it directly addresses the patient's concern and promotes optimal blood sugar control during pregnancy.
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. What sample will be collected for the initial screening process?
- A. Urine
- B. Blood
- C. Saliva
- D. Amniotic fluid
Correct Answer: B
Rationale: AFP screening is done using a blood sample, which is less invasive than an amniocentesis.
A nurse is educating a pregnant patient about the importance of folic acid during pregnancy. Which of the following statements by the patient indicates effective teaching?
- A. I will stop taking folic acid after the first trimester to reduce the risk of birth defects.
- B. Folic acid is important for preventing neural tube defects in the baby's brain and spine.
- C. I can get enough folic acid by eating a healthy diet, so I don't need supplements.
- D. I should take folic acid only if I have a family history of birth defects.
Correct Answer: B
Rationale: Rationale: Choice B is correct because folic acid is indeed important for preventing neural tube defects in the baby's brain and spine. These defects can occur in the early weeks of pregnancy, emphasizing the need for sufficient folic acid intake throughout pregnancy.
Incorrect Choices:
A: Stopping folic acid after the first trimester is not recommended as neural tube development occurs early in pregnancy.
C: While a healthy diet is important, it may not provide enough folic acid during pregnancy, hence supplements are often recommended.
D: Family history of birth defects is not the sole indication for taking folic acid, as all pregnant women benefit from its preventive effects.
A biophysical profile is performed on a pregnant patient. The results show a nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of the hand indicating the presence of fetal tone, and adequate amniotic fluid index (AFI). What is the correct interpretation of this test result?
- A. A score of 10 would indicate that the results are equivocal.
- B. A score of 8 would indicate normal results.
- C. A score of 6 would indicate that birth should be considered as a possible treatment option.
- D. A score of 9 would indicate reassurance.
Correct Answer: B
Rationale: A biophysical profile score of 8-10 is considered normal, indicating fetal well-being.
A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
- A. ensure the birthing person is in a sitting position
- B. check for allergies to anesthesia
- C. ensure informed consent is obtained
- D. administer IV fluids
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically.
Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.