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A multigravid client is 22 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit?
- A. Nausea.
- B. Dyspnea.
- C. Urinary frequency.
- D. Leg cramping.
Correct Answer: D
Rationale: Leg cramping is a common complaint during the second trimester. Nausea is more common in the first trimester, and dyspnea and urinary frequency are more common in the third trimester.
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The nurse is caring for a pregnant patient who is at 36 weeks gestation and reports severe lower back pain. What should the nurse recommend?
- A. Administer pain medication and ensure the patient rests.
- B. Encourage the patient to engage in light physical activity and maintain good posture.
- C. Instruct the patient to apply heat or cold packs to relieve pain.
- D. Encourage the patient to lie flat on her back for extended periods.
Correct Answer: B
Rationale: The correct answer is B because engaging in light physical activity and maintaining good posture can help alleviate lower back pain during pregnancy by strengthening muscles and improving circulation. Resting may worsen the pain. Applying heat or cold packs may provide temporary relief but does not address the underlying issue. Lying flat on her back for extended periods can lead to decreased blood flow to the uterus and potentially harm the baby.
What does optimal nursing care after an amniocentesis include?
- A. Pushing fluids by mouth
- B. Monitoring uterine activity
- C. Placing the patient in a supine position for 2 hours
- D. Applying a pressure dressing to the puncture site
Correct Answer: B
Rationale: Monitoring uterine activity after an amniocentesis is important to detect any contractions that may indicate complications.
A nurse is assisting with a vaginal birth and is monitoring for signs of placental separation. What is the most reliable clinical indicator that the placenta has separated?
- A. a gush of clear amniotic fluid
- B. uterine contractions every 2 to 3 minutes
- C. lengthening of the umbilical cord
- D. maternal report of intense pain
Correct Answer: C
Rationale: The correct answer is C: lengthening of the umbilical cord. This is the most reliable indicator of placental separation because as the placenta detaches from the uterine wall, the cord lengthens as it moves downward. This signifies that the placenta has separated completely.
A: A gush of clear amniotic fluid is not a reliable indicator of placental separation as it can occur before or after placental separation.
B: Uterine contractions every 2 to 3 minutes are a sign of labor progression, not specifically placental separation.
D: Maternal report of intense pain can be subjective and may not always indicate placental separation.
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.
What is the first step the nurse should take when assessing a newborn's respiratory status immediately after birth?
- A. observe for respiratory effort
- B. take the newborn's temperature
- C. assist with suctioning the airways
- D. suction the newborn's mouth
Correct Answer: A
Rationale: The correct answer is A: observe for respiratory effort. This is the first step because it helps the nurse quickly assess if the newborn is breathing effectively. Observing for respiratory effort allows for prompt identification of any potential respiratory distress or abnormalities. Taking the newborn's temperature (B) is important but not the first step in assessing respiratory status. Assisting with suctioning the airways (C) should only be done if there are signs of airway obstruction, not as the initial step. Suctioning the newborn's mouth (D) is not recommended immediately after birth unless there is clear obstruction, as this can stimulate unnecessary reflexes and cause harm.