Nokea
A nurse is caring for a pregnant patient who is at 30 weeks gestation and reports experiencing dizziness and fainting when standing. What is the most likely cause of these symptoms?
- A. Hypotension due to pregnancy-related changes in circulation
- B. Dehydration and electrolyte imbalance
- C. Iron-deficiency anemia
- D. Gestational diabetes causing blood sugar fluctuations
Correct Answer: A
Rationale: The correct answer is A: Hypotension due to pregnancy-related changes in circulation. During pregnancy, blood volume increases, leading to decreased blood pressure when standing. This can cause dizziness and fainting. Dehydration and electrolyte imbalance (B) may cause similar symptoms but are less common in pregnant patients. Iron-deficiency anemia (C) typically presents with fatigue and weakness, not dizziness and fainting. Gestational diabetes (D) usually manifests as high blood sugar levels, not low blood pressure leading to dizziness and fainting.
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The nurse is educating a pregnant patient on the importance of prenatal care. Which statement by the patient indicates the need for further teaching?
- A. Prenatal visits are important to monitor my baby's growth and development.
- B. Prenatal care helps to identify any complications early on.
- C. I will only need to see the doctor once during my pregnancy if everything goes well.
- D. Regular prenatal visits help ensure that I am maintaining good health during pregnancy.
Correct Answer: C
Rationale: The correct answer is C because it suggests a misconception that the patient only needs to see the doctor once during pregnancy. This is incorrect as prenatal care involves multiple visits to monitor both the mother's and baby's health. A: Correct - Prenatal visits monitor baby's growth. B: Correct - Early detection of complications is crucial. D: Correct - Regular visits ensure the mother's health. C: Incorrect - Seeing the doctor only once is inadequate prenatal care and can lead to missed opportunities for early intervention.
A nurse is assessing a laboring person for signs of fetal distress. What is the most common sign of fetal distress?
- A. increase oxygen flow
- B. tachycardia
- C. bradycardia
- D. irregular fetal heart rate
Correct Answer: B
Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.
A woman in her third trimester advises the nurse that she wishes to breastfeed her baby, 'but I don’t think my nipples are right.' Upon examination, the nurse notes that the client has inverted nipples. Which of the following actions should the nurse take at this time?
- A. Advise the client that it is unlikely that she will be able to breastfeed.
- B. Refer the client to a lactation consultant for advice.
- C. Call the labor room and notify them that a client with inverted nipples will be admitted.
- D. Teach the woman exercises to exert her nipples.
Correct Answer: B
Rationale: Inverted nipples can make breastfeeding challenging, but with proper guidance from a lactation consultant, many women are able to breastfeed successfully. Exercises to exert the nipples may also be helpful, but referral to a specialist is the best initial action.
Which food should the nurse advise a pregnant woman to avoid?
- A. Bologna
- B. Cantaloupe
- C. Asparagus
- D. Popcorn
Correct Answer: A
Rationale: Bologna is a processed meat that may contain harmful bacteria like Listeria, posing risks during pregnancy.
The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?
- A. Fetal heart rate via Doppler.
- B. Positive pregnancy test.
- C. Positive Chadwick’s sign.
- D. Montgomery gland enlargements.
Correct Answer: A
Rationale: A fetal heart rate detected via Doppler is a positive sign of pregnancy. A positive pregnancy test, Chadwick’s sign, and Montgomery gland enlargements are probable signs but not definitive.