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A nurse is caring for a pregnant patient at 34 weeks gestation who has been diagnosed with gestational hypertension. What is the nurse's priority intervention?
- A. Encourage the patient to rest and increase fluid intake.
- B. Monitor the patient's blood pressure regularly and assess for signs of preeclampsia.
- C. Administer antihypertensive medications as prescribed.
- D. Instruct the patient to lie on her back to relieve pressure on the uterus.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure regularly and assess for signs of preeclampsia. At 34 weeks gestation with gestational hypertension, monitoring blood pressure and assessing for signs of preeclampsia are crucial to detect any worsening condition. Preeclampsia is a serious complication of gestational hypertension that can lead to adverse outcomes for both the mother and fetus. Regular monitoring allows for timely intervention if necessary.
Choice A is incorrect because simply encouraging rest and increased fluid intake may not address the potential severity of gestational hypertension and preeclampsia.
Choice C is incorrect because administering antihypertensive medications without proper monitoring and assessment can be harmful to the patient and fetus.
Choice D is incorrect because lying on her back can actually worsen the patient's condition by decreasing blood flow to the uterus.
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A nurse is educating a birthing person about the benefits of skin-to-skin contact with their newborn immediately after birth. The nurse explains that this practice has numerous advantages. Which of the following benefits is NOT typically associated with skin-to-skin contact?
- A. improved bonding between parent and baby
- B. enhanced thermoregulation for the newborn
- C. decreased risk of neonatal infections
- D. accelerated uterine involution for the birthing person
Correct Answer: D
Rationale: The correct answer is D: accelerated uterine involution for the birthing person. Skin-to-skin contact does not directly impact the process of uterine involution. The benefits of skin-to-skin contact include improved bonding (A), enhanced thermoregulation (B), and decreased risk of neonatal infections (C). These benefits are well-documented and supported by research. In contrast, uterine involution is a physiological process that occurs naturally postpartum and is not influenced by skin-to-skin contact. Therefore, choice D is the correct answer in this scenario.
The nurse is monitoring her patient during labor and is aware that the only way to determine the objective measurement of uterine contractions is through the use of which modality?
- A. Tocodynamometer
- B. Fetal spiral electrode
- C. IUPC
- D. Palpation
Correct Answer: C
Rationale: The correct answer is C: IUPC (Intrauterine Pressure Catheter). This modality is the only direct and objective measurement of uterine contractions as it provides continuous and precise readings of intrauterine pressure. A: Tocodynamometer measures frequency and duration, but not intensity. B: Fetal spiral electrode monitors fetal heart rate, not uterine contractions. D: Palpation is subjective and not as accurate as IUPC for measuring uterine contractions.
A pregnant patient at 28 weeks gestation reports feeling nauseated and vomiting after meals. What is the most appropriate action for the nurse to take?
- A. Encourage the patient to eat large meals less frequently.
- B. Recommend the patient eat smaller, more frequent meals and avoid greasy foods.
- C. Instruct the patient to rest after meals to reduce nausea.
- D. Advise the patient to avoid all foods until the nausea resolves.
Correct Answer: B
Rationale: The correct answer is B: Recommend the patient eat smaller, more frequent meals and avoid greasy foods. This is because smaller, more frequent meals can help alleviate nausea and vomiting during pregnancy by preventing the stomach from becoming too full. Greasy foods can exacerbate nausea, so avoiding them is beneficial.
A: Encouraging large meals less frequently can worsen symptoms by overwhelming the digestive system.
C: Resting after meals may not directly address the underlying cause of nausea and vomiting.
D: Avoiding all foods can lead to inadequate nutrition for both the patient and the developing fetus.
In summary, choice B is the most appropriate as it addresses the symptoms effectively and promotes better nutrition during pregnancy.
A pregnant patient is at 30 weeks gestation and reports severe heartburn after eating. What is the nurse's most appropriate intervention?
- A. Instruct the patient to take over-the-counter antacids and lie down to relieve symptoms.
- B. Encourage the patient to eat smaller meals and avoid lying down after eating.
- C. Advise the patient to avoid spicy foods and increase protein intake.
- D. Recommend that the patient take proton pump inhibitors for relief.
Correct Answer: B
Rationale: The correct answer is B because encouraging the patient to eat smaller meals and avoid lying down after eating helps prevent stomach acid from refluxing into the esophagus, reducing heartburn. This intervention addresses the root cause of the symptoms during pregnancy. Option A is incorrect as antacids can provide temporary relief but do not prevent heartburn. Option C is incorrect as spicy foods and protein intake do not directly impact heartburn. Option D is incorrect as proton pump inhibitors are not typically recommended during pregnancy due to potential risks to the fetus.
The nurse is caring for a pregnant patient who is 22 weeks gestation and has a history of gestational hypertension. What should the nurse monitor most closely?
- A. Blood glucose levels to check for gestational diabetes
- B. Protein in the urine to assess for preeclampsia
- C. Fetal heart rate to check for signs of fetal distress
- D. Daily weight gain to assess for fluid retention
Correct Answer: B
Rationale: The correct answer is B: Protein in the urine to assess for preeclampsia. The nurse should closely monitor protein in the urine because the patient has a history of gestational hypertension, which puts her at risk for developing preeclampsia. Preeclampsia is characterized by high blood pressure and proteinuria. Monitoring protein in the urine helps detect early signs of preeclampsia, which can lead to serious complications for both the mother and the fetus if left untreated.
Blood glucose levels (A) are not the priority in this case, as the patient's history indicates a higher risk for preeclampsia. Fetal heart rate (C) and daily weight gain (D) are important aspects to monitor during pregnancy; however, in this scenario, the focus should be on detecting signs of preeclampsia due to the patient's history of gestational hypertension.