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A nurse is caring for a pregnant patient who is 26 weeks gestation and reports feeling dizzy when standing. What should the nurse recommend to the patient?
- A. Stand up slowly and make sure to drink plenty of fluids.
- B. Sit down immediately and rest for 10 minutes.
- C. Lie flat on your back to increase blood flow to the brain.
- D. Take deep breaths and elevate your legs while sitting.
Correct Answer: A
Rationale: The correct answer is A: Stand up slowly and make sure to drink plenty of fluids. When a pregnant patient feels dizzy when standing, it is likely due to postural hypotension. Standing up slowly helps prevent a sudden drop in blood pressure, which can cause dizziness. Drinking plenty of fluids helps maintain adequate blood volume and prevents dehydration, another common cause of dizziness during pregnancy. Sitting down immediately (B) may help temporarily but does not address the underlying issue. Lying flat on the back (C) can worsen symptoms by putting pressure on the vena cava, reducing blood flow to the brain. Taking deep breaths and elevating legs (D) may not be effective in addressing postural hypotension.
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A nurse is caring for a laboring person who is experiencing fetal bradycardia. What is the priority nursing intervention?
- A. administer oxygen
- B. administer IV fluids
- C. increase maternal hydration
- D. increase maternal oxygen
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal bradycardia indicates decreased oxygen supply to the fetus, which can lead to fetal distress. Administering oxygen helps improve oxygen levels in the mother's blood, increasing oxygen delivery to the fetus. This intervention is crucial in preventing further complications and ensuring the well-being of the baby. Administering IV fluids (B) and increasing maternal hydration (C) may be beneficial but do not directly address the immediate need for oxygen. Increasing maternal oxygen (D) is redundant since the primary focus should be on fetal oxygenation.
A pregnant patient is at 32 weeks gestation and complains of shortness of breath, swelling of the hands, and increased weight gain. What is the nurse's priority action?
- A. Administer oxygen and prepare the patient for a cesarean section.
- B. Assess the patient's blood pressure and check for protein in the urine.
- C. Encourage the patient to rest and elevate the legs.
- D. Instruct the patient to drink plenty of fluids to reduce swelling.
Correct Answer: B
Rationale: The correct answer is B. At 32 weeks gestation, the patient's symptoms suggest possible preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Assessing blood pressure and checking for proteinuria are crucial for diagnosing and managing preeclampsia. Administering oxygen or preparing for a cesarean section is not the priority without proper assessment. Encouraging rest and elevation of legs may help with swelling, but addressing the potential preeclampsia is more urgent. Instructing the patient to drink fluids is not the priority as it does not address the underlying issue of preeclampsia.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during this stage?
- A. coach the person through controlled pushing
- B. assist with spontaneous pushing
- C. assist with deep breathing
- D. offer non-pharmacological pain relief
Correct Answer: B
Rationale: The correct answer is B because in the second stage of labor, it is appropriate to assist the laboring person with spontaneous pushing to facilitate the descent of the baby through the birth canal. Controlled pushing (choice A) may cause fatigue and unnecessary strain. Deep breathing (choice C) is more suitable for the first stage of labor. Non-pharmacological pain relief (choice D) can be helpful but is not the priority in the second stage when the focus should be on pushing effectively.
A woman in labor requests an epidural. What should the nurse assess before administering the epidural?
- A. Cervical dilation
- B. Maternal blood pressure
- C. Fetal heart rate
- D. Maternal temperature
Correct Answer: B
Rationale: The correct answer is B: Maternal blood pressure. Before administering an epidural, it is crucial to assess the maternal blood pressure to ensure it is within the normal range. Hypotension can occur as a common side effect of epidural anesthesia, which can lead to decreased placental perfusion and compromise fetal oxygenation. Assessing maternal blood pressure helps in preventing potential complications.
Incorrect choices:
A: Cervical dilation - Not directly related to the administration of an epidural.
C: Fetal heart rate - Important but not the immediate assessment needed before administering an epidural.
D: Maternal temperature - While it is important in general assessment, it is not specifically required before giving an epidural.
A nurse is educating a pregnant patient at 32 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is recommended for pregnant patients at 32 weeks gestation. This type of activity helps maintain health without putting excessive strain on the body. Strenuous exercises (Choice A) may increase the risk of injury or complications during pregnancy. Avoiding all physical activity (Choice C) can lead to decreased muscle tone and potential complications. High-impact exercises (Choice D) can be too harsh on the joints and bones during pregnancy. Therefore, moderate exercise is the safest and most beneficial option for pregnant patients at this stage.