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A nurse is assessing a pregnant patient at 36 weeks gestation who complains of pain in the lower abdomen and back. The nurse finds no signs of labor. Which of the following interventions should the nurse implement?
- A. Encourage the patient to rest and monitor for any changes in symptoms.
- B. Administer pain medication and schedule an appointment with the doctor.
- C. Perform a pelvic exam to determine the cause of the pain.
- D. Instruct the patient to remain in bed for the rest of the day.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to rest and monitor for any changes in symptoms. At 36 weeks gestation, the patient might be experiencing Braxton Hicks contractions or round ligament pain, which are common in late pregnancy. Encouraging rest allows for potential relief of discomfort. Monitoring for any changes in symptoms is essential to rule out preterm labor. Option B is incorrect as administering pain medication without identifying the cause may mask symptoms of preterm labor. Option C is incorrect as performing a pelvic exam could potentially cause harm if the patient is experiencing preterm labor. Option D is incorrect as prolonged bed rest is not recommended in pregnancy and may not alleviate the pain or address the underlying cause.
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A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of the following comments by the nurse is appropriate at this time?
- A. We expect you to gain about 1 lb per week, so your weight is a little low at this time.
- B. Most women gain no weight during the first trimester, so I would suggest you eat fewer desserts for the next few weeks.
- C. You entered the pregnancy well underweight, so we should check your diet to make sure you are getting the nutrients you need.
- D. Your weight gain is exactly what we would expect it to be at this time.
Correct Answer: D
Rationale: A weight gain of 3 to 5 lb is expected during the first trimester. The client's weight gain is within the normal range.
A pregnant patient is concerned about the use of caffeine during pregnancy. Which of the following statements by the nurse would be most appropriate?
- A. Caffeine is completely safe during pregnancy and has no impact on the baby.
- B. Moderate caffeine consumption is safe, but it is recommended to limit it to 200 mg per day.
- C. You should avoid caffeine completely to prevent any complications.
- D. Caffeine can cause premature labor, so it should be avoided entirely.
Correct Answer: B
Rationale: The correct answer is B. Moderate caffeine consumption is safe, but it is recommended to limit it to 200 mg per day during pregnancy. This answer is appropriate because it balances the potential risks of caffeine with the benefits of moderate consumption. Excessive caffeine intake has been associated with adverse pregnancy outcomes, so setting a limit is a prudent approach.
Explanation for Incorrect Choices:
A: This statement is incorrect as excessive caffeine intake during pregnancy can have negative effects on the baby.
C: Complete avoidance of caffeine is not necessary unless the individual has specific health concerns that warrant it.
D: While high levels of caffeine can be linked to complications, the statement that caffeine always causes premature labor is an oversimplification.
A nurse is preparing a laboring person for a cesarean birth. What is the priority action before the procedure?
- A. ensure informed consent is signed
- B. administer preoperative medication
- C. administer IV fluids
- D. administer a sedative
Correct Answer: C
Rationale: The correct answer is C: administer IV fluids. Before a cesarean birth, IV fluids are crucial to maintain hydration and prevent hypotension due to anesthesia. Administering IV fluids helps stabilize the person's blood pressure during the procedure, reducing the risk of complications. A is incorrect because informed consent should be obtained earlier in the process. B is incorrect as preoperative medication is typically given closer to the procedure start time. D is incorrect as administering a sedative may affect the person's ability to participate in decision-making and care during the procedure. Administering IV fluids is the priority to ensure the person's safety and well-being during the cesarean birth.
A 40-week pregnant woman is admitted to the labor and delivery unit and is in active labor. Her cervix is 8 cm dilated, and she is experiencing strong contractions. What is the next priority action?
- A. Administer an epidural block
- B. Perform a vaginal examination to assess fetal descent
- C. Assess the fetal heart rate
- D. Prepare for delivery
Correct Answer: C
Rationale: The correct answer is C: Assess the fetal heart rate. This is the next priority action because monitoring the fetal heart rate is crucial to ensure the well-being of the baby during labor. It helps in identifying any signs of fetal distress and guides the healthcare provider in making timely interventions to prevent complications. Administering an epidural block (choice A) can be considered later once the fetal well-being is ensured. Performing a vaginal examination (choice B) may not be necessary at this moment as the woman is already in active labor and has progressed to 8 cm dilation. Preparing for delivery (choice D) should only be done after assessing the fetal well-being to ensure a safe delivery.
A nurse is preparing a laboring person for an epidural. What is the most important nursing action before the procedure?
- A. ensure informed consent is signed
- B. administer pain medication
- C. administer IV fluids
- D. administer an analgesic
Correct Answer: A
Rationale: The correct answer is A: ensure informed consent is signed. Before any procedure, obtaining informed consent is essential to ensure the laboring person understands the risks, benefits, and alternatives of the epidural. This helps promote autonomy and respect for the individual's decision-making. Administering pain medication (choice B), IV fluids (choice C), or an analgesic (choice D) without informed consent is not ethical and violates the principle of autonomy. The focus should be on providing comprehensive information and obtaining consent before proceeding with the intervention.