A nurse is caring for a pregnant patient who is at 20 weeks gestation and reports experiencing leg cramps. What is the nurse's most appropriate intervention?
- A. Recommend taking calcium supplements to relieve leg cramps.
- B. Encourage the patient to elevate the legs and perform leg stretches.
- C. Instruct the patient to rest and avoid any physical activity.
- D. Administer pain medication as needed.
Correct Answer: B
Rationale: The correct answer is B because elevating the legs and performing leg stretches can help improve circulation and relieve leg cramps during pregnancy. This intervention promotes blood flow and prevents muscle fatigue. Calcium supplements (choice A) may be helpful for preventing leg cramps in some cases but are not the first-line intervention. Instructing the patient to rest (choice C) may worsen leg cramps due to decreased circulation. Administering pain medication (choice D) should be avoided unless necessary, as it does not address the root cause of the leg cramps.
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What advice should the nurse give regarding herbal supplements during pregnancy?
- A. Herbals are safe because they're natural
- B. Licorice and cat’s claw are safe
- C. The FDA has approved herbals for pregnancy
- D. Discuss everything with a healthcare provider
Correct Answer: D
Rationale: Herbal supplements may pose risks during pregnancy, and their safety is not well-established. Consulting a healthcare provider is essential.
A pregnant patient at 32 weeks gestation reports occasional dizziness when standing up. What is the nurse's most appropriate recommendation?
- A. Encourage the patient to increase fluid intake and stand up slowly.
- B. Instruct the patient to lie down immediately and rest to prevent fainting.
- C. Advise the patient to avoid physical activity and rest as much as possible.
- D. Instruct the patient to take deep breaths and rise quickly to avoid dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to increase fluid intake and stand up slowly. This recommendation is appropriate because occasional dizziness when standing up can be due to postural hypotension common in pregnancy. Increasing fluid intake helps maintain blood volume, and standing up slowly prevents sudden drops in blood pressure. Choice B is incorrect as lying down immediately may not address the underlying issue. Choice C is incorrect as complete rest may not be necessary. Choice D is incorrect as rising quickly can worsen dizziness.
A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most important intervention to prevent DVT?
- A. administer anticoagulants
- B. administer IV fluids
- C. perform leg exercises
- D. ensure early ambulation
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate hydration which prevents blood from becoming too thick and reduces the risk of clot formation. Adequate hydration also promotes blood circulation, decreasing the risk of DVT. Administering anticoagulants (choice A) is important in managing DVT but is not the most important preventive intervention. Performing leg exercises (choice C) and ensuring early ambulation (choice D) are also beneficial in preventing DVT, but maintaining hydration with IV fluids is the most crucial intervention as it directly addresses the primary factor contributing to DVT formation.
A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
A nurse is assisting a postpartum person with breastfeeding. What is the most important factor for successful breastfeeding?
- A. frequent breastfeeding
- B. proper latch
- C. positioning
- D. administer oxytocin
Correct Answer: B
Rationale: The correct answer is B: proper latch. A proper latch is crucial for successful breastfeeding as it ensures the baby is effectively extracting milk from the breast, preventing nipple soreness and ensuring an adequate milk supply. Without a proper latch, the baby may not receive enough milk, leading to issues such as poor weight gain and frustration for both the baby and the person breastfeeding. Frequent breastfeeding (choice A) is important, but without a proper latch, it may not be effective. Positioning (choice C) is also important, but proper latch takes precedence. Administering oxytocin (choice D) is not necessary for successful breastfeeding and may have side effects.