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A nurse is caring for a patient in labor who is receiving oxytocin for induction. Which of the following is a priority assessment for the nurse?
- A. Fetal heart rate monitoring
- B. Fluid intake and output
- C. Uterine tone assessment
- D. Maternal blood pressure monitoring
Correct Answer: A
Rationale: The correct answer is A: Fetal heart rate monitoring. This is a priority assessment because oxytocin can cause uterine hyperstimulation, leading to fetal distress. Monitoring the fetal heart rate allows early detection of any signs of fetal compromise. Choices B, C, and D are important assessments but not the priority in this situation. Monitoring fluid intake and output, uterine tone, and maternal blood pressure are also crucial but do not directly assess fetal well-being, which is the primary concern during labor induction with oxytocin.
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The nurse is providing prenatal education to a pregnant patient about the signs of labor. Which of the following symptoms should the nurse instruct the patient to report immediately?
- A. Feeling pressure in the lower abdomen
- B. A bloody show or the loss of the mucous plug
- C. Regular contractions every 5 minutes for 1 hour
- D. A sudden increase in fetal movements
Correct Answer: C
Rationale: The correct answer is C: Regular contractions every 5 minutes for 1 hour. This is a sign of active labor and indicates that the patient should seek immediate medical attention. Contractions at this frequency and duration suggest that labor is progressing and the patient should go to the hospital. Choices A, B, and D are not indicative of active labor and do not require immediate medical attention. Feeling pressure in the lower abdomen may be a normal part of pregnancy. A bloody show or loss of the mucous plug can be early signs of labor but do not require immediate attention unless accompanied by other symptoms. A sudden increase in fetal movements is generally considered a positive sign of fetal well-being.
A client is in the 10th week of her pregnancy. Which of the following symptoms would the nurse expect the client to exhibit? Select all that apply.
- A. Backache.
- B. Urinary frequency.
- C. Dyspnea on exertion.
- D. Fatigue.
Correct Answer: A
Rationale: Backache, urinary frequency, and fatigue are common symptoms during the first trimester. Dyspnea on exertion is more common later in pregnancy.
A pregnant patient is at 34 weeks gestation and reports sudden sharp abdominal pain and difficulty breathing. What is the nurse's priority action?
- A. Encourage the patient to lie down and monitor the symptoms.
- B. Administer pain medication and schedule an ultrasound.
- C. Call the healthcare provider immediately and prepare for possible preterm labor.
- D. Assess the fetal heart rate and monitor for contractions.
Correct Answer: C
Rationale: The correct answer is C - Call the healthcare provider immediately and prepare for possible preterm labor. At 34 weeks gestation, sudden sharp abdominal pain and difficulty breathing could indicate a serious complication such as placental abruption or pulmonary embolism. Calling the healthcare provider ensures prompt assessment and appropriate intervention to prevent harm to the mother and baby. Encouraging the patient to lie down may delay necessary intervention. Administering pain medication before determining the cause of pain could mask important symptoms. Assessing the fetal heart rate and monitoring for contractions are important but secondary actions to calling the healthcare provider in this urgent situation.
A couple is preparing to interview obstetric primary care providers to determine who they will go to for care during their pregnancy and delivery.
- A. Take a tour of hospital delivery areas.
- B. Develop a preliminary birth plan.
- C. Make appointments with three or four obstetric care providers.
- D. Search the Internet for the malpractice histories of the providers.
Correct Answer: B
Rationale: Developing a preliminary birth plan helps couples clarify their preferences and priorities, facilitating better communication with potential providers.
A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
- A. ensure the birthing person is in a sitting position
- B. check for allergies to anesthesia
- C. ensure informed consent is obtained
- D. administer IV fluids
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically.
Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.