Nokea
A client at 10 weeks gestation is being seen by the nurse. The client reports that she has nausea and vomiting each morning. Which is the nurse's best response?
- A. Drink a large glass of milk before you get out of bed.
- B. Eat crackers before you get out of bed.
- C. Eat dinner before 6:00 p.m. every night.
- D. Eat small meals during the day.
Correct Answer: B
Rationale: The correct answer is B: Eat crackers before you get out of bed. This is the best response because eating crackers before getting out of bed can help alleviate nausea and vomiting associated with morning sickness in early pregnancy. The crackers can help stabilize blood sugar levels and settle the stomach. Drinking a large glass of milk (choice A) may exacerbate nausea for some individuals. Eating dinner before 6:00 p.m. (choice C) is not directly related to morning sickness. Eating small meals during the day (choice D) is generally a good strategy, but specifically eating crackers before getting out of bed is more effective for morning sickness.
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To reassure and educate pregnant patients about changes in their breasts, nurses should be aware that:
- A. the visibility of blood vessels that form an intertwining blue network indicates full function of Montgomery's tubercles and possibly infection of the tubercles.
- B. the mammary glands do not develop until 2 weeks before labor.
- C. lactation is inhibited until the estrogen level declines after birth.
- D. colostrum is the yellowish oily substance used to lubricate the nipples for breastfeeding.
Correct Answer: A
Rationale: Rationale for Correct Answer A:
1. Montgomery's tubercles are sebaceous glands on the areola.
2. Blood vessels becoming visible indicates increased blood supply due to hormonal changes during pregnancy.
3. The intertwining blue network reflects full function of Montgomery's tubercles.
4. Infection may cause inflammation and increased visibility of blood vessels.
Summary of Incorrect Choices:
B: Incorrect, mammary glands develop during puberty, not right before labor.
C: Incorrect, lactation is primarily influenced by prolactin, not estrogen.
D: Incorrect, colostrum is a thick, yellowish fluid containing antibodies, not an oily substance for lubrication.
During vital sign assessment of a pregnant patient in her third trimester, the patient complains of
feeling faint, dizzy, and agitated. Which nursing intervention is most appropriate?
- A. Which nursing intervention is most appropriate?
- B. Have the patient stand up and retake her blood pressur
- C. Have the patient sit down and hold her arm in a dependent position.
- D. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
Correct Answer: D
Rationale: The correct answer is D: Have the patient turn to her left side and recheck her blood pressure in 5 minutes. This intervention is most appropriate because the patient is experiencing symptoms of potential hypotension, common in pregnant women due to changes in blood volume and hormonal levels. Turning the patient to her left side helps improve blood flow to the heart and can alleviate symptoms. Rechecking the blood pressure in 5 minutes allows for monitoring of any changes.
Choice A is incorrect as it does not provide a specific intervention. Choice B is incorrect as having the patient stand up may worsen symptoms. Choice C is incorrect as holding the arm in a dependent position may not effectively address the underlying issue of hypotension.
A woman is in her seventh month of pregnancy. She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:
- A. this is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
- B. this is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
- C. the woman is a victim of domestic violence and is being hit in the face by her partner.
- D. the woman has been using cocaine intranasally.
Correct Answer: A
Rationale: Rationale:
A: Correct. Nasal congestion and epistaxis are common in pregnancy due to increased estrogen causing mucosal swelling and vasodilation.
B: Incorrect. Nosebleeds are not typically indicative of cardiovascular issues in pregnancy.
C: Incorrect. There is no evidence to suggest domestic violence based on the symptoms provided.
D: Incorrect. Cocaine use would have more severe implications beyond just nasal congestion and epistaxis in pregnancy.
Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester?
- A. Less audible heart sounds (S1, S2)
- B. Increased pulse rate
- C. Increased blood pressure
- D. Decreased red blood cell (RBC) production
Correct Answer: B
Rationale: Between 14 and 20 weeks of gestation, the pulse increases about 10 to 15 beats/min, which persists to term.
A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a:
- A. primipara.
- B. primigravida.
- C. multipara.
- D. nulligravida.
Correct Answer: A
Rationale: A primipara is a woman who has completed one pregnancy with a viable fetus.