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A nurse is caring for a laboring person who is experiencing fetal tachycardia. What is the most appropriate intervention?
- A. administer oxygen
- B. administer IV fluids
- C. monitor maternal vital signs
- D. monitor fetal heart rate continuously
Correct Answer: A
Rationale: Correct Answer: A: Administer oxygen
Rationale: Fetal tachycardia indicates the fetus is not getting enough oxygen. Administering oxygen to the laboring person will help increase oxygen levels in their blood, leading to better oxygen supply to the fetus and potentially improving the fetal heart rate.
Summary of Other Choices:
B: Administering IV fluids may be helpful in some cases, but it is not the priority when dealing with fetal tachycardia.
C: While monitoring maternal vital signs is important, addressing the fetal tachycardia and oxygen supply to the fetus takes precedence.
D: Continuous monitoring of fetal heart rate is essential, but administering oxygen should be the immediate intervention to address the underlying issue of oxygen deficiency.
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A woman in labor begins to experience a sudden increase in vaginal bleeding and the fetal heart rate decelerates. What is the likely cause of these symptoms?
- A. Placenta previa
- B. Placental abruption
- C. Uterine rupture
- D. Cervical laceration
Correct Answer: B
Rationale: The correct answer is B: Placental abruption. Placental abruption is the premature separation of the placenta from the uterine wall, leading to vaginal bleeding and fetal distress. The sudden increase in bleeding and fetal heart rate deceleration are hallmark signs of placental abruption. Placenta previa (choice A) involves bleeding without fetal distress. Uterine rupture (choice C) typically presents with severe abdominal pain and shock. Cervical laceration (choice D) would not cause fetal heart rate deceleration.
A pregnant patient is at 34 weeks gestation and reports persistent lower back pain and difficulty sleeping. What is the nurse's best recommendation for this patient?
- A. Rest in bed and avoid any physical activity.
- B. Use a firm mattress and avoid sleeping on the back.
- C. Take over-the-counter pain medications to alleviate symptoms.
- D. Apply heat to the back and practice good posture while sitting.
Correct Answer: B
Rationale: The correct answer is B: Use a firm mattress and avoid sleeping on the back. This recommendation is appropriate because during pregnancy, the weight of the uterus can compress blood vessels when lying on the back, causing back pain and affecting circulation. Using a firm mattress can provide better support for the back, relieving discomfort. Avoiding sleeping on the back reduces the risk of decreased blood flow to the fetus.
A: Rest in bed and avoid any physical activity is incorrect because it can lead to muscle stiffness and worsen back pain.
C: Taking over-the-counter pain medications may provide temporary relief but does not address the root cause of the discomfort.
D: Applying heat to the back and practicing good posture are helpful strategies, but avoiding sleeping on the back is more crucial to alleviate the symptoms in this case.
At what point in prenatal development do the lungs begin to produce surfactant?
- A. 17 weeks
- B. 20 weeks
- C. 25 weeks
- D. 30 weeks
Correct Answer: C
Rationale: During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur.
A nurse is caring for a pregnant patient who is 12 weeks gestation and reports feeling fatigued. Which of the following is the nurse's most appropriate response?
- A. Fatigue is normal during the first trimester and should improve in the second trimester.
- B. You should rest as much as possible, but try to get up and move regularly to prevent complications.
- C. Fatigue may indicate an underlying medical condition and should be investigated immediately.
- D. I will prescribe iron supplements to help with your fatigue.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Fatigue is common in the first trimester due to hormonal changes and increased energy demands.
2. Second trimester typically brings relief as hormone levels stabilize and energy levels increase.
3. Reassuring the patient about the normalcy of fatigue promotes understanding and reduces anxiety.
Summary:
- Choice B focuses on rest but does not address the normalcy of fatigue in the first trimester.
- Choice C jumps to conclusions without considering common causes first.
- Choice D assumes iron deficiency without assessing the patient's overall health status.
A pregnant patient at 36 weeks gestation reports feeling short of breath when lying flat. What is the nurse's priority action?
- A. Administer oxygen and prepare the patient for delivery.
- B. Encourage the patient to sit up and rest in a more upright position.
- C. Ask the patient to perform deep breathing exercises to improve oxygen flow.
- D. Instruct the patient to take shallow breaths and avoid exertion.
Correct Answer: B
Rationale: The correct answer is B because positioning the pregnant patient in a more upright position can help alleviate the shortness of breath by allowing the diaphragm to move more freely, reducing pressure on the lungs, and improving oxygenation. This action promotes optimal oxygen flow and comfort for the patient.
A: Administering oxygen and preparing for delivery may be necessary in some cases but does not address the immediate need to alleviate shortness of breath caused by the supine position.
C: Deep breathing exercises may not be effective in relieving shortness of breath caused by the supine position and may even exacerbate the discomfort.
D: Instructing the patient to take shallow breaths and avoid exertion does not address the underlying cause of shortness of breath and may not provide adequate relief.