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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.
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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 preparing a laboring person for an epidural. What is the most important nursing action before the procedure?
- A. ensure informed consent is signed
- B. administer pain medication
- C. administer IV fluids
- D. administer an analgesic
Correct Answer: A
Rationale: The correct answer is A: ensure informed consent is signed. Before any procedure, obtaining informed consent is essential to ensure the laboring person understands the risks, benefits, and alternatives of the epidural. This helps promote autonomy and respect for the individual's decision-making. Administering pain medication (choice B), IV fluids (choice C), or an analgesic (choice D) without informed consent is not ethical and violates the principle of autonomy. The focus should be on providing comprehensive information and obtaining consent before proceeding with the intervention.
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 pregnant patient is at 34 weeks gestation and reports frequent headaches and visual changes. What should the nurse do first?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Encourage the patient to rest and drink plenty of fluids.
- C. Administer pain medication as prescribed to relieve the headache.
- D. Schedule an appointment with an eye specialist to check for vision changes.
Correct Answer: A
Rationale: The correct answer is A. At 34 weeks gestation, headaches and visual changes can be signs of preeclampsia, a serious pregnancy complication. The nurse should first monitor the patient's blood pressure as elevated BP is a key indicator of preeclampsia. Assessing for other signs like proteinuria and edema is crucial for early detection and timely intervention. Encouraging rest and fluids (choice B) may not address the underlying issue. Administering pain medication (choice C) only masks symptoms without addressing the potential serious condition. Scheduling an eye specialist appointment (choice D) is not the priority as the symptoms are more indicative of a systemic issue like preeclampsia.
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.