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A nurse is caring for a laboring person who is experiencing fetal tachycardia. What is the priority intervention?
- A. administer oxygen
- B. monitor fetal heart rate
- C. increase fluid intake
- D. increase oxygen flow
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal tachycardia indicates decreased oxygen supply to the fetus. Administering oxygen helps improve oxygenation to the fetus, addressing the root cause. Monitoring fetal heart rate (B) is important but not the priority over addressing the oxygen supply. Increasing fluid intake (C) does not directly address the fetal tachycardia. Increasing oxygen flow (D) is not necessary if the person is already receiving sufficient oxygen.
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The nurse is assessing a pregnant patient who is at 14 weeks gestation and reports light vaginal bleeding. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and check for protein in the urine.
- B. Call the healthcare provider immediately to assess for miscarriage.
- C. Encourage the patient to rest and wait for symptoms to resolve.
- D. Perform a pelvic exam to check for cervical dilation.
Correct Answer: B
Rationale: The correct answer is B: Call the healthcare provider immediately to assess for miscarriage. The priority action in this scenario is to promptly notify the healthcare provider to assess for potential complications like miscarriage, which could be life-threatening to the patient or fetus. This step ensures timely intervention and appropriate management. Monitoring blood pressure and urine for protein (Choice A) is important but not the immediate priority. Encouraging rest and waiting for symptoms to resolve (Choice C) may delay necessary medical intervention. Performing a pelvic exam (Choice D) could potentially worsen the situation if miscarriage is occurring. Thus, calling the healthcare provider for assessment is the most appropriate and urgent action to take in this situation.
A nurse is educating a pregnant patient about warning signs to report during pregnancy. Which of the following statements indicates that the teaching has been effective?
- A. I should report any sudden increase in swelling, especially in my hands and face.
- B. I should wait until after my due date to report any concerns.
- C. I should only report changes in fetal movement after the third trimester.
- D. I don't need to report headaches or blurry vision unless they are severe.
Correct Answer: A
Rationale: The correct answer is A because sudden increase in swelling, especially in hands and face, can indicate preeclampsia, a serious condition during pregnancy. Swelling in these areas can be a sign of fluid retention and increased blood pressure. Prompt reporting and intervention are crucial to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because:
B: Waiting until after the due date to report concerns can lead to missed opportunities for early intervention and can be dangerous for both the mother and the baby.
C: Changes in fetal movement should be reported immediately, not just after the third trimester, as they can indicate fetal distress.
D: Headaches and blurry vision, even if not severe, can be symptoms of preeclampsia or other serious conditions that require immediate attention. Waiting for symptoms to worsen can be harmful.
A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
- A. ensure the birthing person is positioned correctly
- B. check for allergies to anesthesia
- C. administer a test dose of anesthesia
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
A woman missed her menstrual period 1 week ago and has come to the doctor’s office for a pregnancy test. Which placental hormone is measured in pregnancy tests?
- A. Progesterone
- B. Estrogen
- C. Human chorionic gonadotropin
- D. Human placental lactogen
Correct Answer: C
Rationale: Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.
Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following?
- A. Avoid eating greasy foods.
- B. Drink orange juice before rising.
- C. Consume 1 teaspoon of nutmeg each morning.
- D. Eat 3 large meals plus a bedtime snack.
Correct Answer: A
Rationale: Greasy foods can exacerbate nausea and vomiting. Small, frequent meals are recommended, and saltine crackers before rising can help alleviate symptoms. Orange juice and nutmeg are not recommended.