Nokea
A client enters the prenatal clinic. She states that she believes she is pregnant. Which of the following hormone elevations will indicate a high probability that the client is pregnant?
- A. Chorionic gonadotropin.
- B. Oxytocin.
- C. Prolactin.
- D. Luteinizing hormone.
Correct Answer: A
Rationale: Chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests and is a definitive indicator of pregnancy. Oxytocin, prolactin, and luteinizing hormone are not specific to pregnancy.
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What response is appropriate regarding sushi consumption during pregnancy?
- A. Fish is healthy
- B. Sushi is too salty
- C. Raw fish is high in mercury
- D. Fish should be cooked
Correct Answer: D
Rationale: Cooking fish destroys harmful bacteria and parasites, reducing the risk of foodborne illnesses during pregnancy.
A nurse is caring for a laboring person who is experiencing irregular fetal heart rate patterns. What is the most appropriate intervention?
- A. increase oxygen flow
- B. increase fetal monitoring
- C. administer an analgesic
- D. increase fluid intake
Correct Answer: B
Rationale: The correct answer is B, to increase fetal monitoring. This is crucial to assess the fetal well-being and identify any potential distress or complications early on. Monitoring allows for timely interventions to be implemented to optimize outcomes. Increasing oxygen flow (A) may be necessary in some cases, but it is not the initial priority. Administering an analgesic (C) may help with pain management but does not address the fetal heart rate patterns. Increasing fluid intake (D) is important for hydration but is not directly related to managing fetal heart rate patterns.
Which of the following vital sign changes should the nurse highlight for a pregnant woman’s obstetrician?
- A. Prepregnancy blood pressure (BP) 100/60 and third trimester BP 140/90.
- B. Prepregnancy respiratory rate (RR) 16 rpm and third trimester RR 22 rpm.
- C. Prepregnancy heart rate (HR) 76 bpm and third trimester HR 88 bpm.
- D. Prepregnancy temperature (T) 98.6°F and third trimester T 99.2°F.
Correct Answer: A
Rationale: A significant increase in blood pressure, particularly to 140/90, could indicate preeclampsia and should be highlighted for further evaluation. The other changes are within normal limits for pregnancy.
A pregnant patient is at 32 weeks gestation and reports a sudden headache and visual disturbances. What is the nurse's priority action?
- A. Encourage the patient to lie down and rest for a while.
- B. Assess the patient's blood pressure and check for protein in the urine.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to drink a caffeinated beverage to relieve symptoms.
Correct Answer: B
Rationale: The correct answer is B because sudden headache and visual disturbances in a pregnant patient at 32 weeks gestation could indicate preeclampsia. Assessing blood pressure and checking for protein in the urine are crucial steps in diagnosing preeclampsia, a serious condition that requires immediate medical attention to prevent complications for both the mother and baby. Encouraging rest, administering pain medication, or suggesting caffeinated beverages may mask symptoms but not address the underlying issue of preeclampsia. Therefore, prompt assessment and monitoring of blood pressure and urine protein levels are essential in this scenario.
The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination.
- A. Orthopneic.
- B. Lateral-recumbent.
- C. Sims'.
- D. Semi-Fowler’s.
Correct Answer: B
Rationale: The lateral-recumbent position reduces pressure on the inferior vena cava and is safer for pregnant women compared to other positions.