Nokea
A client is in the 10th week of her pregnancy. Which of the following symptoms would the nurse expect the client to exhibit? Select all that apply.
- A. Backache.
- B. Urinary frequency.
- C. Dyspnea on exertion.
- D. Fatigue.
Correct Answer: A
Rationale: Backache, urinary frequency, and fatigue are common symptoms during the first trimester. Dyspnea on exertion is more common later in pregnancy.
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The nurse is caring for a pregnant patient who has been diagnosed with gestational diabetes. Which of the following interventions should be implemented first?
- A. Administer insulin to control blood glucose levels.
- B. Instruct the patient to follow a diabetic diet and monitor blood glucose levels.
- C. Schedule a cesarean delivery due to the risk of macrosomia.
- D. Start the patient on antihypertensive medications to control blood pressure.
Correct Answer: B
Rationale: The correct answer is B because instructing the patient to follow a diabetic diet and monitor blood glucose levels is the initial intervention for managing gestational diabetes. This step is crucial in controlling blood glucose levels and preventing complications for both the mother and the baby. Administering insulin (option A) may be necessary but is not the first step. Scheduling a cesarean delivery (option C) is not indicated unless there are specific obstetric indications. Starting the patient on antihypertensive medications (option D) is not relevant for managing gestational diabetes unless the patient also has hypertension.
A 30-year-old pregnant patient is at 36 weeks gestation and expresses concerns about swelling in her legs. Which of the following assessments is most important for the nurse to make?
- A. Assess the patient's weight gain during the pregnancy.
- B. Examine the legs for any signs of deep vein thrombosis (DVT).
- C. Instruct the patient to elevate her legs and rest.
- D. Evaluate the patient's dietary intake of sodium.
Correct Answer: B
Rationale: The correct answer is B: Examine the legs for any signs of deep vein thrombosis (DVT). At 36 weeks gestation, pregnant women are at higher risk for DVT due to increased blood volume and pressure on the veins from the growing uterus. DVT can be life-threatening if not detected early. Assessing for any signs of DVT such as redness, warmth, swelling, or pain in the legs is crucial for prompt intervention.
Incorrect choices:
A: Assessing weight gain is important but not the priority in this situation where DVT is a concern.
C: Instructing the patient to elevate her legs and rest can help with swelling but does not address the potential serious complication of DVT.
D: Evaluating dietary intake of sodium is not the priority in this situation where DVT is a concern.
A nurse is caring for a patient in labor who is receiving oxytocin for induction. Which of the following is a priority assessment for the nurse?
- A. Fetal heart rate monitoring
- B. Fluid intake and output
- C. Uterine tone assessment
- D. Maternal blood pressure monitoring
Correct Answer: A
Rationale: The correct answer is A: Fetal heart rate monitoring. This is a priority assessment because oxytocin can cause uterine hyperstimulation, leading to fetal distress. Monitoring the fetal heart rate allows early detection of any signs of fetal compromise. Choices B, C, and D are important assessments but not the priority in this situation. Monitoring fluid intake and output, uterine tone, and maternal blood pressure are also crucial but do not directly assess fetal well-being, which is the primary concern during labor induction with oxytocin.
What alternative could the nurse suggest to someone practicing pica?
- A. Replace laundry starch with salt
- B. Replace ice with frozen fruit juice
- C. Replace soap with cream cheese
- D. Replace soil with uncooked pie crust
Correct Answer: B
Rationale: Replacing ice with frozen fruit juice provides a safer alternative while satisfying the craving for cold substances.
A pregnant patient at 32 weeks gestation is concerned about gestational diabetes. What is the nurse's priority intervention?
- A. Encourage the patient to eat smaller, more frequent meals and monitor blood glucose levels.
- B. Administer insulin as prescribed to control blood glucose levels.
- C. Recommend a high-protein, low-carbohydrate diet to prevent blood sugar spikes.
- D. Instruct the patient to limit fluid intake to reduce blood sugar fluctuations.
Correct Answer: A
Rationale: The correct answer is A because it addresses the immediate concern of managing blood glucose levels in a pregnant patient with gestational diabetes. Encouraging smaller, more frequent meals helps stabilize blood sugar levels and prevent spikes. Monitoring blood glucose levels is crucial for timely interventions. Administering insulin (B) may be necessary but not the priority. A high-protein, low-carb diet (C) is not typically recommended for gestational diabetes. Limiting fluid intake (D) is not appropriate as hydration is important during pregnancy. In summary, choice A is the priority as it directly addresses the patient's concern and promotes optimal blood sugar control during pregnancy.