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A gravida, G1 P0000, is having her first prenatal physical examination. Which of the following assessments should the nurse inform the client that she will have that day? Select all that apply.
- A. Pap smear.
- B. Mammogram.
- C. Glucose challenge test.
- D. Biophysical profile.
Correct Answer: A
Rationale: A Pap smear and complete blood count are standard assessments during the first prenatal visit. A mammogram, glucose challenge test, and biophysical profile are not typically performed at this stage.
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The nurse working in an outpatient obstetric office assesses four primigravid clients. Which of the client findings should the nurse highlight for the physician? Select all that apply.
- A. 17 weeks’ gestation; denies feeling fetal movement.
- B. 24 weeks’ gestation; fundal height at the umbilicus.
- C. 27 weeks’ gestation; salivates excessively.
- D. 34 weeks’ gestation; experiences uterine cramping.
Correct Answer: A
Rationale: Denial of fetal movement at 17 weeks and uterine cramping at 34 weeks are concerning findings that should be highlighted for further evaluation. Fundal height at the umbilicus at 24 weeks and excessive salivation at 27 weeks are within normal limits.
A patient asks the nurse when her infant’s heart will begin to pump blood. What will the nurse reply?
- A. By the end of week 3
- B. Beginning in week 8
- C. At the end of week 16
- D. Beginning in week 24
Correct Answer: A
Rationale: The fetal heart begins to pump by week 3 of gestation.
A pregnant patient is 26 weeks gestation and is concerned about gaining too much weight. What is the nurse's most appropriate response?
- A. Weight gain should be monitored, but it is important to eat for two during pregnancy.
- B. Pregnant women are encouraged to maintain a healthy weight gain and eat a balanced diet.
- C. Excessive weight gain can result in complications such as gestational diabetes and preeclampsia.
- D. It is better to limit caloric intake to prevent excessive weight gain.
Correct Answer: C
Rationale: The correct answer is C because excessive weight gain during pregnancy can lead to complications like gestational diabetes and preeclampsia. As the nurse, it is important to educate the patient on the risks associated with excessive weight gain. By highlighting these potential complications, the nurse can emphasize the importance of monitoring weight gain and making healthy choices. Choices A and B are incorrect as they do not address the risks of excessive weight gain. Choice D is also incorrect as it suggests limiting caloric intake, which may not provide adequate nutrition for the growing fetus. It is crucial to educate the patient on the importance of a balanced diet and healthy weight gain to promote a healthy pregnancy.
A 24-year-old patient is in labor and requests pain relief. What is the most appropriate intervention for a patient who is in the active phase of labor?
- A. Administer an epidural block
- B. Provide non-pharmacological pain relief methods
- C. Administer narcotic analgesics
- D. Encourage the patient to push with each contraction
Correct Answer: A
Rationale: The correct answer is A: Administer an epidural block. In the active phase of labor, the pain is typically intense and continuous. Administering an epidural block can provide effective pain relief by blocking nerve signals, allowing the patient to rest and conserve energy for the pushing phase. It does not affect the ability to push and can improve maternal satisfaction. Non-pharmacological methods (B) may not provide sufficient relief at this stage. Narcotic analgesics (C) can cross the placenta and affect the baby's respiratory system. Encouraging the patient to push (D) is appropriate during the second stage of labor, not the active phase.
A nurse is caring for a patient in labor who is experiencing intense pain. Which of the following would be the most appropriate intervention to manage pain during labor?
- A. Encourage the patient to practice deep breathing and relaxation techniques.
- B. Administer intravenous fluids to reduce pain sensation.
- C. Provide a sedative to help the patient rest between contractions.
- D. Suggest an epidural to block pain completely.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to practice deep breathing and relaxation techniques. This is the most appropriate intervention to manage pain during labor because deep breathing and relaxation techniques can help the patient to cope with the pain, reduce stress, and promote a sense of control. These techniques are safe, non-invasive, and can be effective in managing labor pain without the need for medication or invasive procedures.
Summary:
- Choice B (Administer intravenous fluids): Intravenous fluids do not directly reduce pain sensation and are not a primary intervention for managing labor pain.
- Choice C (Provide a sedative): Sedatives may affect the baby and can interfere with the progress of labor. They do not address the root cause of pain during labor.
- Choice D (Suggest an epidural): While epidurals can provide effective pain relief, they are not always necessary or desired by all patients. Encouraging non-pharmacological methods first is often preferred.