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A nurse is assisting a laboring person with an epidural. What is the most important nursing intervention prior to the procedure?
- A. ensure proper positioning
- B. ensure informed consent
- C. monitor contractions
- D. assist with controlled breathing
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent. This is crucial before any medical procedure, including epidural administration. It ensures the laboring person understands the risks, benefits, and alternatives of the epidural. Proper positioning (choice A) is important during the procedure but not the most critical pre-procedure intervention. Monitoring contractions (choice C) and assisting with breathing (choice D) are important aspects of labor support but not directly related to obtaining informed consent for the epidural.
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When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make?
- A. You are effectively meeting your daily fruit requirements.
- B. Fruit juices are excellent sources of folic acid.
- C. It would be even better if you were to consume more whole fruits and less fruit juice.
- D. Your fruit intake far exceeds the recommended daily fruit intake.
Correct Answer: C
Rationale: Whole fruits provide fiber and additional nutrients compared to fruit juices, which may contain added sugars. Encouraging increased consumption of whole fruits aligns with healthy dietary guidelines for pregnancy.
A woman delivers a fetal demise that has lanugo covering the entire body, nails that are present on the fingers and toes, but eyes that are still fused. Prior to the death, the mother stated that she had felt quickening. Based on this information, the nurse knows that the baby is about how many weeks’ gestation?
- A. 15 weeks.
- B. 22 weeks.
- C. 29 weeks.
- D. 36 weeks.
Correct Answer: B
Rationale: Lanugo typically appears around 16-20 weeks and covers the entire body by 22-24 weeks. Nails begin forming at around 18-20 weeks and are fully developed by 22 weeks. Fused eyelids occur up until about 24-26 weeks, after which they open. Quickening (feeling of fetal movement) usually occurs between 18-22 weeks in first-time pregnancies. Therefore, the most likely gestational age is 22 weeks.
What part of the fetal body derives from the mesoderm?
- A. Nails
- B. Oil glands
- C. Muscles
- D. Lining of the bladder
Correct Answer: C
Rationale: The mesoderm is responsible for the development of muscles. Nails and oil glands derive from the ectoderm. The lining of the bladder derives from the endoderm.
A client who was seen in the prenatal clinic at 20 weeks’ gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks’ gestation?
- A. 129 to 130 lb.
- B. 131 to 132 lb.
- C. 133 to 134 lb.
- D. 135 to 136 lb.
Correct Answer: C
Rationale: A weight gain of 1 lb per week is expected during the second and third trimesters. Therefore, the client should gain approximately 4 lb between 20 and 24 weeks.
The nurse is caring for a pregnant patient who has a history of gestational hypertension. Which intervention is most important to reduce the risk of complications?
- A. Monitor blood pressure regularly during pregnancy.
- B. Encourage the patient to exercise vigorously.
- C. Instruct the patient to eat a high-sodium diet.
- D. Advise the patient to reduce her fluid intake to avoid edema.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood pressure regularly during pregnancy. Regular monitoring is crucial to detect any changes in blood pressure early and intervene promptly to prevent complications like preeclampsia.
Choice B is incorrect because vigorous exercise can increase blood pressure. Choice C is incorrect as a high-sodium diet can worsen hypertension. Choice D is incorrect as reducing fluid intake can lead to dehydration and potentially exacerbate hypertension. Regular blood pressure monitoring is key in managing gestational hypertension and ensuring the best outcomes for both the mother and the baby.