Nokea
A client who was seen in the prenatal clinic at 20 weeks’ gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks’ gestation?
- A. 129 to 130 lb.
- B. 131 to 132 lb.
- C. 133 to 134 lb.
- D. 135 to 136 lb.
Correct Answer: C
Rationale: A weight gain of 1 lb per week is expected during the second and third trimesters. Therefore, the client should gain approximately 4 lb between 20 and 24 weeks.
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A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
- A. ensure the birthing person is positioned correctly
- B. check for allergies to anesthesia
- C. administer a test dose of anesthesia
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
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.
The nurse is assessing a pregnant patient who is 30 weeks gestation and reports pain in the lower abdomen and back. What should the nurse do first?
- A. Assess for signs of preterm labor, including regular contractions.
- B. Administer pain medication and advise the patient to rest.
- C. Encourage the patient to perform light physical activity to relieve the pain.
- D. Instruct the patient to lie flat on her back and monitor the symptoms.
Correct Answer: A
Rationale: The correct answer is A because pain in the lower abdomen and back could indicate preterm labor at 30 weeks gestation. The first step is to assess for signs of preterm labor, such as regular contractions, to determine the urgency of the situation. Administering pain medication (B) without assessing the cause can mask symptoms. Encouraging physical activity (C) may worsen preterm labor. Instructing the patient to lie flat on her back (D) can decrease blood flow to the uterus and is not recommended in late pregnancy.
What is the priority intervention for a laboring person with a suspected uterine rupture?
- A. prepare for an emergency cesarean section
- B. perform uterine massage
- C. apply pressure to the abdomen
- D. monitor the fetal heart rate continuously
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation.
Incorrect choices:
A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial.
C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications.
D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.
A nurse is educating a pregnant patient about the importance of folic acid supplementation. Which of the following statements by the patient indicates the need for further teaching?
- A. Folic acid helps prevent birth defects in the baby's brain and spine.
- B. I should start taking folic acid before I become pregnant to ensure its benefits.
- C. I can stop taking folic acid after the first trimester because the baby's development is complete.
- D. Folic acid should be taken daily throughout the pregnancy to reduce the risk of birth defects.
Correct Answer: C
Rationale: Rationale:
C is the correct answer because stopping folic acid after the first trimester is incorrect. Folic acid is crucial for the baby's neural tube development, which occurs in the early stages of pregnancy. Therefore, discontinuing supplementation after the first trimester could increase the risk of neural tube defects. Choices A, B, and D are incorrect because they emphasize the importance of folic acid in preventing birth defects and highlight the necessity of consistent supplementation throughout pregnancy for optimal benefits.