Nokea
A nurse is caring for a pregnant patient who is at 40 weeks gestation and reports leaking clear fluid. What is the nurse's priority action?
- A. Check the fetal heart rate and assess the mother's vital signs.
- B. Encourage the patient to go home and rest until contractions begin.
- C. Instruct the patient to monitor fetal movement and call back if the fluid continues to leak.
- D. Call the healthcare provider immediately to report the rupture of membranes.
Correct Answer: D
Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.
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An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.
- A. Amenorrhea.
- B. Breast tenderness.
- C. Quickening.
- D. Frequent urination.
Correct Answer: A
Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.
A pregnant patient is 28 weeks gestation and is concerned about gaining too much weight. Which of the following is most important for the nurse to emphasize?
- A. Weight gain should be within the recommended range for pregnancy, and any concerns should be discussed with the healthcare provider.
- B. The patient should not worry about weight gain, as it is inevitable during pregnancy.
- C. Excessive weight gain can increase the risk of complications such as gestational diabetes and preeclampsia.
- D. The patient should limit caloric intake to avoid gaining more than the recommended amount of weight.
Correct Answer: C
Rationale: The correct answer is C because excessive weight gain during pregnancy can indeed increase the risk of complications such as gestational diabetes and preeclampsia. By emphasizing this point, the nurse can help the patient understand the importance of monitoring their weight gain to promote a healthy pregnancy.
Choice A is not as strong because it focuses more on discussing concerns with the healthcare provider rather than the specific risks associated with excessive weight gain. Choice B is incorrect as weight gain during pregnancy should be monitored and managed appropriately. Choice D is also incorrect as it suggests limiting caloric intake, which may not be safe or appropriate for the patient and her developing fetus.
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.
A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy?
- A. Influenza.
- B. Mumps.
- C. Rubella.
- D. Varicella.
Correct Answer: A
Rationale: Influenza vaccination is safe and recommended during pregnancy to protect both the mother and fetus. Vaccines for Mumps, Rubella, and Varicella are live attenuated vaccines and are contraindicated during pregnancy.
A pregnant patient is at 24 weeks gestation and reports feeling fatigued and weak. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to rest and avoid physical activity.
- B. Assess the patient's hemoglobin and hematocrit levels to check for anemia.
- C. Recommend that the patient eat a high-calorie diet to increase energy.
- D. Encourage the patient to perform regular exercise to combat fatigue.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's hemoglobin and hematocrit levels to check for anemia. Fatigue and weakness in pregnancy can be symptoms of anemia, a common condition due to increased blood volume demands. By checking hemoglobin and hematocrit levels, the nurse can confirm or rule out anemia as the cause. Resting alone may not address the underlying issue, and high-calorie diet or regular exercise may not be appropriate if anemia is present. It is crucial to identify the root cause to provide the most effective intervention.