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A client at 20 weeks' gestation reports leg cramps. What recommendation should the nurse provide?
- A. Increase potassium intake.
- B. Stretch the legs before bed.
- C. Drink fluids during meals.
- D. Reduce physical activity.
Correct Answer: B
Rationale: The correct answer is B: Stretch the legs before bed. Leg cramps during pregnancy are common due to increased weight and pressure on blood vessels. Stretching before bed helps prevent cramps by improving circulation and muscle relaxation. Increasing potassium intake (choice A) can help with muscle function but is not the primary intervention for leg cramps. Drinking fluids during meals (choice C) is important for hydration but does not directly address leg cramps. Reducing physical activity (choice D) may worsen circulation and muscle cramps.
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The nurse is preparing a client for induction of labor. What is the purpose of administering oxytocin?
- A. Stimulate uterine contractions.
- B. Relieve pain during labor.
- C. Promote cervical ripening.
- D. Reduce maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Stimulate uterine contractions. Oxytocin is administered to induce labor by increasing the frequency and strength of uterine contractions. This helps progress labor and facilitate delivery. Choice B is incorrect as pain relief is usually achieved through analgesics or anesthesia. Choice C is incorrect because cervical ripening is typically promoted with medications like prostaglandins. Choice D is also incorrect as oxytocin can actually cause a temporary increase in blood pressure.
Which intervention should the nurse prioritize for a pregnant client with placenta previa?
- A. Monitor the client for contractions
- B. Prepare for immediate cesarean delivery
- C. Monitor for signs of fetal distress
- D. Encourage the client to remain in bed rest
Correct Answer: B
Rationale: The correct answer is B: Prepare for immediate cesarean delivery. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. Immediate cesarean delivery is the priority to prevent maternal and fetal complications. Monitoring for contractions (A) is important but not the priority. Monitoring for fetal distress (C) is crucial but not the immediate intervention. Encouraging bed rest (D) may be recommended but is not the priority intervention in placenta previa.
A woman is 16 weeks pregnant and she had cramping backache and mild bleeding for the past 3 days. The HCP determines she is dilated 2cm, 10% effaced, membranes intact. She's crying and saying to the nurse is my baby going to be okay? In addition to acknowledging the patient's fear the nurse should also say:
- A. Your cervix has begun to dilate, this is a serious sign, we will continue to monitor you and the baby for now
- B. I really can't say but when your physicians arrive, I'll ask her talk to you about it
- C. You baby will be fine, we will start an IV and get this stopped in no time at all
- D. You are going to miscarry, but you should be relieved because most miscarriages are the result of abnormalities in the fetus
Correct Answer: A
Rationale: Step 1: Acknowledge the patient's fear and anxiety.
Step 2: Provide a clear and honest response regarding the situation.
Step 3: Explain the significance of cervical dilation at 16 weeks.
Step 4: Assure the patient that they will be closely monitored.
Step 5: Offer support and comfort to the patient.
Summary:
Choice A is correct because it addresses the patient's concerns, acknowledges the seriousness of the situation, provides information about cervical dilation, and reassures the patient about monitoring. Choices B, C, and D are incorrect because they do not provide accurate information or address the situation appropriately, which could further distress the patient.
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action before the procedure?
- A. Administer IV fluids.
- B. Obtain baseline vital signs.
- C. Ensure informed consent is signed.
- D. Position the client in the Trendelenburg position.
Correct Answer: C
Rationale: The correct answer is C: Ensure informed consent is signed. Before any invasive procedure like an amniocentesis, it is essential to ensure that the client has full understanding of the risks, benefits, and alternatives. This is crucial for autonomy and ethical practice. Administering IV fluids (choice A) is not a priority before an amniocentesis. Obtaining baseline vital signs (choice B) is important but not the priority over informed consent. Positioning the client in the Trendelenburg position (choice D) is not necessary for an amniocentesis procedure.