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A nurse is assessing a postpartum person for signs of urinary retention. What is the most common sign of urinary retention in the postpartum period?
- A. Abdominal distension
- B. Frequent voiding
- C. No voiding for several hours
- D. Urinary urgency
Correct Answer: C
Rationale: The correct answer is C: No voiding for several hours. Postpartum urinary retention is common due to trauma during childbirth. The bladder may be unable to contract effectively, leading to a lack of sensation to void. This can result in no voiding for several hours. Abdominal distension (A) is not specific to urinary retention. Frequent voiding (B) and urinary urgency (D) are not characteristic signs of urinary retention; they are more indicative of overactive bladder or urinary tract infection.
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A nurse is caring for a laboring person who is experiencing fetal bradycardia. What is the priority nursing intervention?
- A. administer oxygen
- B. administer IV fluids
- C. increase maternal hydration
- D. increase maternal oxygen
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal bradycardia indicates decreased oxygen supply to the fetus, which can lead to fetal distress. Administering oxygen helps improve oxygen levels in the mother's blood, increasing oxygen delivery to the fetus. This intervention is crucial in preventing further complications and ensuring the well-being of the baby. Administering IV fluids (B) and increasing maternal hydration (C) may be beneficial but do not directly address the immediate need for oxygen. Increasing maternal oxygen (D) is redundant since the primary focus should be on fetal oxygenation.
A pregnant patient at 32 weeks gestation reports increased pressure in the pelvic area and mild cramping. What should the nurse assess first?
- A. The fetal heart rate and signs of labor.
- B. The patient's blood pressure and urine for protein.
- C. The presence of vaginal discharge or bleeding.
- D. The patient's dietary intake and hydration status.
Correct Answer: A
Rationale: The correct answer is A: The fetal heart rate and signs of labor. At 32 weeks gestation, any pelvic pressure and cramping could be indicative of preterm labor, which is a critical concern. Assessing the fetal heart rate can help determine fetal well-being and signs of distress. Monitoring for signs of labor such as contractions, cervical changes, and rupture of membranes is essential for timely intervention.
Choice B: Assessing blood pressure and urine for protein is important in monitoring for preeclampsia, but it is not the priority in this case where signs of preterm labor are reported.
Choice C: Vaginal discharge or bleeding could indicate various conditions, but in this scenario, the focus should be on ruling out preterm labor first.
Choice D: Dietary intake and hydration status are important aspects of prenatal care, but they are not the priority when assessing a pregnant patient reporting pelvic pressure and cramping at 32 weeks gestation.
A woman in labor begins to experience severe lower abdominal pain and is found to have a ruptured uterus. What is the first intervention the nurse should perform?
- A. Administer intravenous fluids
- B. Prepare the patient for immediate surgery
- C. Perform a vaginal examination
- D. Administer pain relief medications
Correct Answer: B
Rationale: The correct answer is B: Prepare the patient for immediate surgery. In the case of a ruptured uterus, prompt surgical intervention is crucial to control bleeding, repair the uterus, and prevent further complications such as hemorrhage and infection. Performing surgery is the priority over other interventions like administering fluids, pain relief medications, or performing a vaginal examination, as these actions do not address the immediate life-threatening situation of uterine rupture. Administering IV fluids may be necessary during surgery, and pain relief can be addressed post-operatively. Vaginal examination is contraindicated in cases of suspected uterine rupture as it can exacerbate the bleeding and worsen the condition.
A pregnant patient at 28 weeks gestation is experiencing severe swelling in her hands and feet. Which of the following actions should the nurse take first?
- A. Assess the patient's blood pressure and check for signs of preeclampsia.
- B. Encourage the patient to elevate her legs and rest.
- C. Monitor the patient's urine output and report any changes.
- D. Schedule an ultrasound to assess fetal growth and amniotic fluid levels.
Correct Answer: A
Rationale: The correct action to take first is to assess the patient's blood pressure and check for signs of preeclampsia (Answer A). Preeclampsia is a serious condition characterized by high blood pressure and signs of organ dysfunction. In this scenario, the patient's severe swelling could be indicative of preeclampsia, which poses a risk to both the mother and the fetus. By assessing blood pressure and looking for other signs of preeclampsia, the nurse can determine the urgency of the situation and take appropriate actions to manage the condition.
Encouraging leg elevation and rest (Answer B) may help alleviate some symptoms but does not address the underlying cause of the swelling. Monitoring urine output (Answer C) is important for overall assessment but does not address the immediate concern of potential preeclampsia. Scheduling an ultrasound (Answer D) is not the priority in this situation as it does not provide information about the patient's current condition and does not address the
A pregnant patient at 26 weeks gestation reports dizziness and faintness when standing. Which intervention should the nurse prioritize?
- A. Encourage the patient to drink plenty of fluids and avoid standing for long periods.
- B. Instruct the patient to rise quickly from a seated position.
- C. Encourage the patient to lie flat on her back and rest.
- D. Advise the patient to take iron supplements to prevent dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink plenty of fluids and avoid standing for long periods. This intervention addresses the symptoms of dizziness and faintness by preventing dehydration and orthostatic hypotension common during pregnancy. Fluid intake maintains blood volume, reducing the risk of hypotension. Avoiding prolonged standing helps prevent blood pooling in the lower extremities. Choices B and C could exacerbate symptoms by causing sudden changes in blood pressure. Choice D is incorrect as iron supplements do not directly address the immediate issue of dizziness and faintness related to dehydration and orthostatic hypotension during pregnancy.