Nokea
A client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?
- A. Administer tocolytic medication.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.
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A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread.
- B. A sliced apple and red grapes.
- C. A chocolate chip cookie with a glass of skim milk.
- D. A scrambled egg with cheddar cheese.
Correct Answer: B
Rationale: Phenylketonuria (PKU) is a genetic disorder where the body cannot metabolize phenylalanine, an amino acid found in protein-containing foods. Patients with PKU need to follow a strict low-phenylalanine diet to prevent the buildup of phenylalanine in the body. Fruits like apples and grapes are low in protein and contain minimal phenylalanine, making them suitable choices for individuals with PKU. The other options listed contain higher amounts of protein and phenylalanine, such as peanut butter, chocolate chip cookies, milk, scrambled eggs, and cheese, which should be avoided by individuals with PKU.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action?
- A. Verify signed informed consent.
- B. Administer prescribed analgesics.
- C. Encourage the client to empty their bladder.
- D. Position the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.
A client in labor receiving an epidural reports feeling lightheaded and nauseous. What is the nurse's priority intervention?
- A. Administer antiemetics as prescribed.
- B. Check maternal blood pressure.
- C. Increase the oxytocin infusion rate.
- D. Encourage the client to lie on her back.
Correct Answer: B
Rationale: Lightheadedness and nausea can be signs of hypotension, a common side effect of epidural anesthesia.
The nurse is caring for a client in labor with an epidural. What assessment is most important immediately after placement?
- A. Monitor maternal temperature.
- B. Assess for lower extremity weakness.
- C. Monitor maternal blood pressure.
- D. Check fetal presentation.
Correct Answer: C
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension caused by epidural anesthesia.
The nurse is educating a client about exercises during pregnancy. What activity should be avoided?
- A. Swimming.
- B. Walking.
- C. Contact sports.
- D. Prenatal yoga.
Correct Answer: C
Rationale: Contact sports pose a risk of trauma to the mother and fetus and should be avoided during pregnancy.