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A nurse is caring for a laboring person who is in the first stage of labor. What is the priority assessment during this stage?
- A. monitor fetal heart rate
- B. assess cervical dilation
- C. assist with positioning
- D. administer an epidural
Correct Answer: A
Rationale: The correct answer is A: monitor fetal heart rate. During the first stage of labor, assessing the fetal heart rate is crucial to ensure the well-being of the baby. It helps detect any signs of distress or complications early on. Monitoring the mother's health is also important, but ensuring the baby's safety takes precedence. Assessing cervical dilation (B) is important but not the priority in the early stage. Assisting with positioning (C) can help progress labor but is secondary to monitoring fetal well-being. Administering an epidural (D) is not a priority assessment but a pain management intervention.
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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 nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits?
- A. Leg cramps.
- B. Varicose veins.
- C. Hemorrhoids.
- D. Fainting spells.
Correct Answer: A
Rationale: Leg cramps, varicose veins, and hemorrhoids are common complaints during pregnancy due to increased blood volume and pressure on the lower extremities. Fainting spells are not considered normal and may indicate an underlying issue.
A pregnant patient at 36 weeks gestation reports difficulty breathing when lying flat. What should the nurse do first?
- A. Encourage the patient to rest in a semi-reclined position or on her left side.
- B. Administer oxygen as prescribed to improve oxygenation.
- C. Monitor the fetal heart rate and assess for signs of distress.
- D. Instruct the patient to take shallow breaths and stay in bed.
Correct Answer: A
Rationale: The correct answer is A because positioning the patient in a semi-reclined or left side position can alleviate pressure on the diaphragm and improve breathing. This position helps optimize blood flow to the uterus and placenta. Encouraging rest in this position can improve oxygenation for both the mother and fetus. Administering oxygen (Choice B) may help with oxygenation but does not address the underlying issue of positional discomfort. Monitoring fetal heart rate (Choice C) is important but not the first action to address the mother's breathing difficulty. Instructing the patient to take shallow breaths and stay in bed (Choice D) does not address the positional component of the issue.
A nurse is caring for a laboring person who is receiving oxytocin for labor induction. What is the priority intervention when uterine hyperstimulation occurs?
- A. stop the oxytocin infusion
- B. increase the oxytocin infusion
- C. administer IV fluids
- D. administer an epidural
Correct Answer: D
Rationale: The correct answer is D: administer an epidural. Uterine hyperstimulation during labor can lead to fetal distress and complications. Administering an epidural can help manage pain and relax the uterus, reducing the risk of hyperstimulation. Stopping the oxytocin infusion (choice A) is also important, but managing the uterine contractions with an epidural takes priority. Increasing the oxytocin infusion (choice B) would exacerbate the hyperstimulation. Administering IV fluids (choice C) may be helpful, but it does not directly address the uterine hyperstimulation.
The nurse is assessing a pregnant patient in the second trimester who is complaining of leg cramps. Which of the following interventions is most appropriate?
- A. Encourage the patient to take a hot bath to relieve the cramps.
- B. Instruct the patient to elevate her legs while resting.
- C. Recommend regular stretching exercises to prevent cramps.
- D. Suggest that the patient take calcium supplements to prevent cramps.
Correct Answer: B
Rationale: The correct answer is B. Elevating her legs while resting helps improve circulation and reduce the risk of leg cramps in pregnant patients. This position promotes blood flow and reduces the pressure on the blood vessels. Choices A and D do not directly address improving circulation or reducing pressure on blood vessels. Choice C, while beneficial in general, may not provide immediate relief for the current leg cramps. Therefore, elevating the legs while resting is the most appropriate intervention for the pregnant patient experiencing leg cramps in the second trimester.