Nokea
A nurse is educating a pregnant patient about preeclampsia. Which of the following statements by the patient indicates the need for further teaching?
- A. I should report sudden swelling in my hands, face, or feet.
- B. I should monitor my blood pressure and avoid excessive salt in my diet.
- C. I should expect occasional headaches and dizziness as normal symptoms of pregnancy.
- D. I should contact my healthcare provider if I experience sudden vision changes or severe headaches.
Correct Answer: C
Rationale: Rationale: Choice C is incorrect because headaches and dizziness are not considered normal symptoms of pregnancy, especially when accompanied by other signs of preeclampsia. Preeclampsia can cause headaches and dizziness due to high blood pressure. Choices A, B, and D are correct as they highlight important signs and symptoms of preeclampsia that the patient should report to their healthcare provider promptly.
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During the fourth stage of labor, a nurse assesses the perineum of a birthing person who had a vaginal birth. What is the primary purpose of this assessment?
- A. to evaluate the birthing person's readiness for discharge
- B. to ensure the birthing person can ambulate safely
- C. to detect any signs of perineal trauma
- D. to assess the status of cervical dilation
Correct Answer: C
Rationale: The primary purpose of assessing the perineum during the fourth stage of labor is to detect any signs of perineal trauma. This assessment is crucial to identify any tears or lacerations that may require immediate medical attention. By checking for perineal trauma, the nurse can ensure proper healing and prevent complications postpartum.
Summary:
A: Evaluating readiness for discharge is not the primary purpose of perineal assessment during the fourth stage of labor.
B: Ensuring safe ambulation is important but not the primary reason for assessing the perineum.
D: Assessing cervical dilation is not relevant during the fourth stage of labor where the focus shifts to monitoring postpartum recovery.
The nurse has made it a goal to increase the rate at which women begin prenatal care in the first trimester. The nurse relates this decision to national goals for better maternal and infant outcomes. What guidelines will the nurse use to guide her maternal health goals?
- A. WHO Maternal care guidelines
- B. State Practice Acts
- C. AWHONN white papers
- D. Healthy People 2020
Correct Answer: D
Rationale: The correct answer is D: Healthy People 2020. The nurse will use Healthy People 2020 guidelines because they are evidence-based, nationally recognized objectives that focus on improving the health and well-being of individuals, families, and communities. These guidelines specifically address maternal and infant health outcomes, making them the most relevant choice for the nurse's goal.
Incorrect Choices:
A: WHO Maternal care guidelines - While WHO guidelines are important, they are not specific to the national goals and objectives the nurse is trying to align with.
B: State Practice Acts - State Practice Acts govern the scope of practice for nurses and do not provide specific guidelines for maternal health goals.
C: AWHONN white papers - AWHONN provides valuable resources, but they may not be as comprehensive or nationally recognized as Healthy People 2020 for setting maternal health goals.
A pregnant patient at 32 weeks gestation reports swelling in the feet and hands. What should the nurse do first?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Encourage the patient to elevate her feet and rest for 30 minutes.
- C. Recommend that the patient drink more water and reduce sodium intake.
- D. Assess the patient for signs of a blood clot or deep vein thrombosis.
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 32 weeks gestation, swelling in the feet and hands can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Monitoring blood pressure is crucial as elevated blood pressure is a key indicator of preeclampsia. Assessing for other signs of preeclampsia such as headache, visual disturbances, or upper abdominal pain is important for early detection and management. Prompt intervention is necessary to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because while elevation of feet, rest, hydration, and reducing sodium intake are important in managing mild swelling during pregnancy, in this case, the priority is to rule out preeclampsia which can lead to severe complications if left untreated. Assessing for blood clots or deep vein thrombosis is also important but
A nurse is caring for a pregnant patient who is at 22 weeks gestation and reports experiencing vaginal bleeding. What is the nurse's priority action?
- A. Encourage the patient to rest and avoid strenuous activity.
- B. Monitor the fetal heart rate and assess for any signs of preterm labor.
- C. Assess the bleeding and notify the healthcare provider immediately.
- D. Instruct the patient to use a sanitary pad to monitor for changes in bleeding.
Correct Answer: C
Rationale: The correct answer is C: Assess the bleeding and notify the healthcare provider immediately. This is the priority action because vaginal bleeding during pregnancy can indicate serious complications such as placental abruption or preterm labor. By assessing the bleeding, the nurse can determine the severity and nature of the bleeding to provide crucial information to the healthcare provider for prompt intervention. Notifying the healthcare provider immediately ensures timely assessment and appropriate management to protect the health and well-being of both the mother and fetus. Encouraging rest (choice A) may be appropriate, but assessing the bleeding and notifying the healthcare provider take precedence. Monitoring fetal heart rate (choice B) is important but secondary to assessing the bleeding. Instructing the patient to use a sanitary pad (choice D) is not sufficient to address the potential underlying causes of vaginal bleeding.
A patient in labor is undergoing an epidural block and develops hypotension. What should the nurse do first?
- A. Increase intravenous fluids
- B. Place the patient in a Trendelenburg position
- C. Administer oxygen via face mask
- D. Notify the physician immediately
Correct Answer: A
Rationale: The correct first action is to increase intravenous fluids (Choice A). This will help improve the patient's blood volume and subsequently increase blood pressure. Trendelenburg position (Choice B) is not recommended due to potential complications. Administering oxygen (Choice C) may be helpful but doesn't directly address the hypotension. Notifying the physician (Choice D) is important but addressing hypotension promptly is the priority. Increasing fluids helps address the underlying cause of hypotension in this scenario.