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A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?
- A. Perform a vaginal exam to assess for fetal position
- B. Prepare the patient for delivery
- C. Administer an epidural block
- D. Continue to monitor contractions and fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.
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A pregnant patient is 28 weeks gestation and is concerned about gaining too much weight. Which of the following is most important for the nurse to emphasize?
- A. Weight gain should be within the recommended range for pregnancy, and any concerns should be discussed with the healthcare provider.
- B. The patient should not worry about weight gain, as it is inevitable during pregnancy.
- C. Excessive weight gain can increase the risk of complications such as gestational diabetes and preeclampsia.
- D. The patient should limit caloric intake to avoid gaining more than the recommended amount of weight.
Correct Answer: C
Rationale: The correct answer is C because excessive weight gain during pregnancy can indeed increase the risk of complications such as gestational diabetes and preeclampsia. By emphasizing this point, the nurse can help the patient understand the importance of monitoring their weight gain to promote a healthy pregnancy.
Choice A is not as strong because it focuses more on discussing concerns with the healthcare provider rather than the specific risks associated with excessive weight gain. Choice B is incorrect as weight gain during pregnancy should be monitored and managed appropriately. Choice D is also incorrect as it suggests limiting caloric intake, which may not be safe or appropriate for the patient and her developing fetus.
The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?
- A. Inadequate space in the uterus
- B. Inadequate blood supply
- C. Inadequate maternal health
- D. Inadequate placental nutrition
Correct Answer: D
Rationale: The single placenta may not be able to provide adequate nutrition to two fetuses.
A nurse is assessing a 26-week pregnant patient who is concerned about stretch marks. Which of the following interventions should the nurse suggest?
- A. Use over-the-counter creams and lotions to prevent stretch marks.
- B. There are no effective interventions to prevent stretch marks, but moisturizing the skin can help reduce discomfort.
- C. Take vitamin supplements to improve skin elasticity and prevent stretch marks.
- D. Stretch marks can be completely prevented by staying hydrated and exercising regularly.
Correct Answer: B
Rationale: The correct answer is B because stretch marks are primarily influenced by genetics and skin elasticity. Moisturizing the skin can help reduce discomfort associated with stretch marks but cannot prevent them entirely. A is incorrect because over-the-counter creams are not proven to prevent stretch marks. C is incorrect because while some vitamins may promote skin health, they cannot completely prevent stretch marks. D is incorrect because while staying hydrated and exercising are important for overall health, they cannot guarantee the prevention of stretch marks.
A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
- A. Instruct the patient to avoid standing for long periods.
- B. Encourage the patient to increase sodium intake.
- C. Recommend that the patient take frequent naps during the day.
- D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.
A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
- A. Magnesium sulfate
- B. Prostaglandin suppository
- C. RhoGAM if the patient is Rh-negative
- D. Betamethasone
Correct Answer: C
Rationale: Rh-negative women undergoing CVS require RhoGAM to prevent Rh sensitization.