Nokea
A gravid woman and her husband inform the nurse that they have just moved into a three-story home that was built in the 1930s. Which of the following is critical for the nurse to advise the woman to protect the unborn child?
- A. Stay out of any rooms that are being renovated.
- B. Drink water only from the hot water tap.
- C. Refrain from entering the basement.
- D. Climb the stairs only once per day.
Correct Answer: A
Rationale: Renovations in older homes may release lead dust or asbestos, which are harmful to the developing fetus. Drinking water from the hot tap, limiting stair climbing, or avoiding basements are less critical concerns compared to exposure to renovation hazards.
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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.
A pregnant patient at 32 weeks gestation reports a sudden headache and blurred vision. What is the nurse's priority action?
- A. Assess the patient's blood pressure and check for signs of preeclampsia.
- B. Administer pain medication and advise the patient to rest.
- C. Encourage the patient to drink fluids and take deep breaths.
- D. Perform a visual acuity test and schedule a follow-up appointment.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's blood pressure and check for signs of preeclampsia. This is the priority action because sudden headache and blurred vision are symptoms of preeclampsia, a serious condition in pregnancy. Step 1: Assessing blood pressure is crucial to identify hypertension, a hallmark of preeclampsia. Step 2: Checking for other signs of preeclampsia, such as proteinuria and edema, helps confirm the diagnosis. Step 3: Prompt intervention is necessary to prevent complications for both the mother and the baby. Choices B, C, and D are incorrect because they do not address the potential life-threatening condition of preeclampsia and may delay appropriate treatment.
A nurse is caring for a 38-week pregnant patient who is experiencing a decrease in fetal movement. Which of the following should be the nurse's first action?
- A. Encourage the patient to drink a cold beverage and lie down.
- B. Instruct the patient to wait 24 hours and monitor fetal movements.
- C. Order an ultrasound to check the baby's health.
- D. Call the healthcare provider immediately to report the decrease in movement.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a cold beverage and lie down. This is the correct action as it promotes fetal movement by stimulating the baby with a change in temperature and position. It is a non-invasive and immediate measure that can be taken by the patient herself.
Choice B is incorrect because waiting 24 hours could delay necessary intervention if the fetus is in distress. Choice C is incorrect as ordering an ultrasound may not be the most immediate or necessary action at this point. Choice D is incorrect as calling the healthcare provider immediately may not be necessary if the issue can be resolved by the patient changing her position and trying to stimulate fetal movement first.
A nurse is caring for a postpartum person who is at risk for postpartum hemorrhage. What is the most important nursing action to reduce the risk?
- A. administer oxytocin
- B. administer IV fluids
- C. administer an epidural
- D. perform fundal massage
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate circulating volume, preventing hypovolemia which is a major risk factor for postpartum hemorrhage. This action supports blood pressure and perfusion to reduce the risk of excessive bleeding. Administering oxytocin (A) helps with uterine contraction but does not address the underlying issue of hypovolemia. Administering an epidural (C) is not directly related to preventing postpartum hemorrhage. Fundal massage (D) is important but not the most critical action in reducing the risk of postpartum hemorrhage.
A 40-year-old primiparous woman who is 38 weeks pregnant has been on the labor unit for an hour when she starts to complain of feeling dizzy, light-headed, and nauseous. Her blood pressure is 90/60. What should be the first response of the nurse?
- A. Give the patient a bolus of intravenous fluid.
- B. Turn the patient to her left side.
- C. Call the obstetrician or nurse midwife.
- D. Give the patient an antiemetic medication for the nausea.
Correct Answer: B
Rationale: The correct answer is B: Turn the patient to her left side.
Rationale:
1. The patient's symptoms of dizziness, light-headedness, and low blood pressure (90/60) suggest hypotension, which could be due to supine hypotensive syndrome in pregnancy.
2. Turning the patient to her left side can help alleviate pressure on the vena cava, improving blood flow back to the heart and subsequently increasing blood pressure.
3. This immediate action can help prevent further complications such as decreased placental perfusion and fetal distress.
Summary:
- Choice A (Give the patient a bolus of intravenous fluid): While IV fluids may be needed, the priority is to address the underlying cause of hypotension first.
- Choice C (Call the obstetrician or nurse midwife): While it is important to involve the healthcare provider, immediate action to address the hypotension is crucial.
- Choice D (Give the patient an antiemetic medication for