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A nurse is assessing a pregnant patient at 18 weeks gestation who complains of feeling lightheaded when standing. What should the nurse advise the patient to do?
- A. Take deep breaths and lie flat on your back.
- B. Increase fluid intake and avoid standing for long periods.
- C. Take frequent rests while sitting upright.
- D. Change positions slowly and sit down immediately if feeling faint.
Correct Answer: D
Rationale: The correct answer is D because changing positions slowly helps prevent a sudden drop in blood pressure, which can cause lightheadedness. Sitting down immediately if feeling faint promotes safety and prevents falls. Taking deep breaths and lying flat on the back (choice A) can exacerbate lightheadedness by reducing blood flow to the brain. Increasing fluid intake and avoiding prolonged standing (choice B) may help with other issues but may not directly address the lightheadedness. Taking frequent rests while sitting upright (choice C) does not address the issue of changing positions slowly to prevent lightheadedness.
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Which dairy product should the client avoid during pregnancy?
- A. Vanilla yogurt
- B. Parmesan cheese
- C. Gorgonzola cheese
- D. Chocolate milk
Correct Answer: C
Rationale: Gorgonzola cheese is a soft, mold-ripened cheese that may contain Listeria, posing a risk during pregnancy.
How long should clamping of the cord be delayed in an uncomplicated delivery to increase the newborn's hemoglobin levels and improve circulation?
- A. 30–60 seconds
- B. 15–30 seconds
- C. 30 seconds
- D. Delayed cord clamping is not recommended.
Correct Answer: A
Rationale: The correct answer is A (30-60 seconds) for delayed cord clamping in an uncomplicated delivery. Delaying cord clamping for 30-60 seconds allows more blood to flow from the placenta to the baby, increasing the baby's hemoglobin levels and improving circulation. This extra blood transfer can provide the baby with essential nutrients and oxygen, reducing the risk of anemia and improving overall health outcomes.
Choice B (15-30 seconds) may not provide enough time for sufficient blood transfer compared to the optimal window of 30-60 seconds.
Choice C (30 seconds) is within the recommended range, but 30-60 seconds is considered more beneficial for maximizing blood flow to the newborn.
Choice D (Delayed cord clamping is not recommended) is incorrect as delayed cord clamping has been shown to have various benefits for newborns when done in uncomplicated deliveries.
A pregnant woman states, “My husband hopes I will give him a boy because we have three girls.” What will the nurse explain to this woman?
- A. The sex chromosome of the fertilized ovum determines the gender of the child.
- B. When the sperm and ovum are united, there is a 75% chance the child will be a girl.
- C. When the pH of the female reproductive tract is acidic, the child will be a girl.
- D. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.
Correct Answer: D
Rationale: When a Y-bearing sperm fertilizes an ovum, a male child is produced.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and is experiencing a sudden increase in vaginal discharge. What is the nurse's priority action?
- A. Check for signs of labor and assess fetal heart rate.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Perform a pelvic exam to assess the amount of discharge.
- D. Call the healthcare provider immediately to report the change in discharge.
Correct Answer: A
Rationale: The correct answer is A because the sudden increase in vaginal discharge at 40 weeks gestation could indicate the onset of labor. Checking for signs of labor, such as contractions and assessing fetal heart rate, is crucial to determine if the patient is in active labor. This helps in timely intervention and ensuring the well-being of both the mother and baby.
Summary:
- Choice B: Encouraging rest and monitoring changes in discharge may not address the urgency of the situation.
- Choice C: Performing a pelvic exam without assessing signs of labor or fetal well-being may delay necessary actions.
- Choice D: While reporting to the healthcare provider is important, immediate assessment of labor signs and fetal heart rate takes precedence.
A pregnant patient has received the results of her triple-screen testing and it is positive. What would the nurse anticipate as the next step in the patient’s plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: A positive triple-screen test suggests an increased risk of genetic abnormalities, requiring additional diagnostic testing.