Maternal Monitoring

Maternal Monitoring Related

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A nurse is assessing a pregnant patient who is at 34 weeks gestation and reports swelling in the legs and feet. What is the nurse's priority action?

  • A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
  • B. Encourage the patient to rest with her feet elevated.
  • C. Administer a diuretic to reduce swelling.
  • D. Instruct the patient to reduce fluid intake to decrease swelling.
Correct Answer: A

Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 34 weeks gestation, swelling in the legs and feet can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. The priority action is to assess for signs of preeclampsia, as it can lead to severe complications for both the mother and the baby. Monitoring blood pressure is crucial in identifying preeclampsia early.

Choice B is incorrect because while elevating the feet may provide some relief from swelling, it does not address the potential underlying issue of preeclampsia. Choice C is incorrect because administering a diuretic without assessing for preeclampsia can be dangerous and potentially harmful to the patient and the baby. Choice D is incorrect because reducing fluid intake can lead to dehydration, which is not a recommended approach in pregnancy without proper assessment and guidance from healthcare providers.

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A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?

  • A. apply warm compresses
  • B. apply cold compresses
  • C. provide distraction techniques
  • D. apply lanolin cream
Correct Answer: B

Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.

The nurse is providing prenatal education to a pregnant patient at 20 weeks gestation. Which of the following actions should the nurse prioritize?

  • A. Assessing the patient for signs of gestational hypertension.
  • B. Encouraging the patient to avoid all forms of exercise.
  • C. Reviewing newborn care practices and breastfeeding options.
  • D. Discussing the signs and symptoms of preterm labor.
Correct Answer: D

Rationale: The correct answer is D: Discussing the signs and symptoms of preterm labor. This is crucial at 20 weeks gestation as preterm labor can occur. By educating the patient on the signs and symptoms, the nurse can empower her to recognize and seek prompt medical attention if needed. Assessing for gestational hypertension (A) is important but typically done later in pregnancy. Encouraging avoidance of all forms of exercise (B) is not recommended as moderate exercise is beneficial during pregnancy. Reviewing newborn care practices and breastfeeding options (C) is important but not the priority at this stage.

Which food should the nurse advise a pregnant woman to avoid?

  • A. Bologna
  • B. Cantaloupe
  • C. Asparagus
  • D. Popcorn
Correct Answer: A

Rationale: Bologna is a processed meat that may contain harmful bacteria like Listeria, posing risks during pregnancy.

An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.

  • A. Amenorrhea.
  • B. Breast tenderness.
  • C. Quickening.
  • D. Frequent urination.
Correct Answer: A

Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.

The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?

  • A. Inadequate space in the uterus
  • B. Inadequate blood supply
  • C. Inadequate maternal health
  • D. Inadequate placental nutrition
Correct Answer: D

Rationale: The single placenta may not be able to provide adequate nutrition to two fetuses.

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