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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A nurse is educating a pregnant patient about the importance of folic acid during pregnancy. Which of the following statements by the patient indicates effective teaching?
- A. I will stop taking folic acid after the first trimester to reduce the risk of birth defects.
- B. Folic acid is important for preventing neural tube defects in the baby's brain and spine.
- C. I can get enough folic acid by eating a healthy diet, so I don't need supplements.
- D. I should take folic acid only if I have a family history of birth defects.
Correct Answer: B
Rationale: Rationale: Choice B is correct because folic acid is indeed important for preventing neural tube defects in the baby's brain and spine. These defects can occur in the early weeks of pregnancy, emphasizing the need for sufficient folic acid intake throughout pregnancy.
Incorrect Choices:
A: Stopping folic acid after the first trimester is not recommended as neural tube development occurs early in pregnancy.
C: While a healthy diet is important, it may not provide enough folic acid during pregnancy, hence supplements are often recommended.
D: Family history of birth defects is not the sole indication for taking folic acid, as all pregnant women benefit from its preventive effects.
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.
Which of the following is the most important nursing intervention for a laboring person who is receiving oxytocin for induction of labor?
- A. monitor for signs of uterine hyperstimulation
- B. monitor fetal heart rate continuously
- C. provide emotional support
- D. encourage ambulation
Correct Answer: B
Rationale: The correct answer is B: monitor fetal heart rate continuously. This is crucial because oxytocin can cause uterine hyperstimulation leading to fetal distress. Continuous monitoring allows for early detection of fetal compromise. Monitoring for signs of uterine hyperstimulation (A) is important but secondary to fetal well-being. Emotional support (C) and encouraging ambulation (D) are beneficial but not as critical as ensuring fetal safety during oxytocin administration.
A nurse is educating a pregnant patient about warning signs to report during pregnancy. Which of the following statements indicates that the teaching has been effective?
- A. I should report any sudden increase in swelling, especially in my hands and face.
- B. I should wait until after my due date to report any concerns.
- C. I should only report changes in fetal movement after the third trimester.
- D. I don't need to report headaches or blurry vision unless they are severe.
Correct Answer: A
Rationale: The correct answer is A because sudden increase in swelling, especially in hands and face, can indicate preeclampsia, a serious condition during pregnancy. Swelling in these areas can be a sign of fluid retention and increased blood pressure. Prompt reporting and intervention are crucial to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because:
B: Waiting until after the due date to report concerns can lead to missed opportunities for early intervention and can be dangerous for both the mother and the baby.
C: Changes in fetal movement should be reported immediately, not just after the third trimester, as they can indicate fetal distress.
D: Headaches and blurry vision, even if not severe, can be symptoms of preeclampsia or other serious conditions that require immediate attention. Waiting for symptoms to worsen can be harmful.
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.