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A nurse is assessing a laboring person for signs of uterine rupture. What is the most common sign of uterine rupture?
- A. abdominal pain
- B. vaginal bleeding
- C. decreased fetal movement
- D. increased fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: decreased fetal movement. Uterine rupture can lead to decreased blood flow to the fetus, resulting in reduced fetal movement. This sign is crucial as it indicates fetal distress and the need for immediate medical intervention. Abdominal pain (A) can be present but is not specific to uterine rupture. Vaginal bleeding (B) is a sign of placental abruption, not uterine rupture. Increased fetal heart rate (D) can occur due to fetal distress, but decreased fetal movement is a more direct sign of uterine rupture.
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A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?
- A. Perform a vaginal exam to assess for fetal position
- B. Prepare the patient for delivery
- C. Administer an epidural block
- D. Continue to monitor contractions and fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.
A pregnant patient is at 30 weeks gestation and is experiencing dizziness and lightheadedness when standing. What is the nurse's first priority action?
- A. Encourage the patient to drink fluids and rest for 10 minutes.
- B. Instruct the patient to lie flat on her back to restore circulation.
- C. Monitor the patient's blood pressure and check for signs of anemia.
- D. Administer oxygen and prepare for immediate delivery.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink fluids and rest for 10 minutes. This is the first priority action because dizziness and lightheadedness in a pregnant patient at 30 weeks gestation could be due to orthostatic hypotension, a common issue in pregnancy. Encouraging the patient to drink fluids and rest will help increase blood volume and alleviate symptoms.
Choice B is incorrect because lying flat on her back can worsen symptoms due to supine hypotensive syndrome. Choice C is not the first priority as checking for anemia or monitoring blood pressure should come after addressing immediate symptoms. Choice D is incorrect because immediate delivery is not warranted based on the symptoms described.
A nurse is caring for a pregnant patient who is at 30 weeks gestation and reports experiencing dizziness and fainting when standing. What is the most likely cause of these symptoms?
- A. Hypotension due to pregnancy-related changes in circulation
- B. Dehydration and electrolyte imbalance
- C. Iron-deficiency anemia
- D. Gestational diabetes causing blood sugar fluctuations
Correct Answer: A
Rationale: The correct answer is A: Hypotension due to pregnancy-related changes in circulation. During pregnancy, blood volume increases, leading to decreased blood pressure when standing. This can cause dizziness and fainting. Dehydration and electrolyte imbalance (B) may cause similar symptoms but are less common in pregnant patients. Iron-deficiency anemia (C) typically presents with fatigue and weakness, not dizziness and fainting. Gestational diabetes (D) usually manifests as high blood sugar levels, not low blood pressure leading to dizziness and fainting.
A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immediately if she experiences which of the following signs/symptoms? Select all that apply.
- A. Convulsions.
- B. Double vision.
- C. Epigastric pain.
- D. Persistent vomiting.
Correct Answer: D
Rationale: These symptoms may indicate severe complications such as preeclampsia, eclampsia, or hyperemesis gravidarum, requiring immediate medical attention. Polyuria is generally not a danger sign.
The nurse is caring for a pregnant patient who is 37 weeks gestation and is experiencing contractions every 10 minutes. Which of the following should the nurse assess first?
- A. The patient's vital signs and fetal heart rate
- B. The patient's cervical dilation and effacement
- C. The patient's urinary output and fluid balance
- D. The patient's emotional status and support system
Correct Answer: B
Rationale: The correct answer is B: The patient's cervical dilation and effacement. At 37 weeks gestation with contractions every 10 minutes, assessing cervical dilation and effacement is crucial to determine if the patient is in active labor. This information will guide the nurse in determining the appropriate next steps for the patient's care, such as the need for further monitoring or interventions. Assessing vital signs and fetal heart rate (Choice A) is important but not the priority in this scenario. Urinary output and fluid balance (Choice C) are important considerations but not the immediate priority. Emotional status and support system (Choice D) are also important but not the first assessment to be made in this situation.