Nokea
A nurse is educating a pregnant patient about signs of labor. Which of the following statements by the patient indicates a need for further teaching?
- A. I should be concerned if I have regular contractions every 10 minutes.
- B. If I notice a bloody show, I should call my healthcare provider.
- C. The loss of my mucous plug means that labor is starting right away.
- D. If I experience my water breaking, I should go to the hospital immediately.
Correct Answer: C
Rationale: The correct answer is C. The loss of the mucous plug does not necessarily indicate that labor is starting right away. It can happen days to weeks before labor begins. A: Regular contractions every 10 minutes suggest labor progression. B: A bloody show can indicate the onset of labor. D: Water breaking is a sign of labor and requires immediate medical attention. Therefore, the patient needs further teaching on the timing and significance of losing the mucous plug.
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A pregnant patient who is 18 weeks gestation reports that she has not felt her baby move for several hours. What should the nurse instruct the patient to do?
- A. Drink a cold beverage and lie down to count fetal movements.
- B. Wait until the morning and report any continued lack of movement to your doctor.
- C. Rest and refrain from worrying, as it is common for fetal movements to decrease.
- D. Call your doctor immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A because decreased fetal movement could indicate a potential problem. Drinking a cold beverage and lying down can stimulate the baby to move, allowing the patient to count fetal movements. This can help assess the baby's well-being. Choice B is incorrect as waiting can delay necessary intervention. Choice C is incorrect as decreased fetal movement should not be dismissed without assessment. Choice D is incorrect as immediate action is needed but calling the doctor alone may not provide immediate relief or guidance.
A pregnant patient is at 24 weeks gestation and reports pain in her lower abdomen and back. What is the nurse's first priority action?
- A. Administer pain medication and encourage rest.
- B. Assess the patient for signs of preterm labor, including regular contractions.
- C. Instruct the patient to perform relaxation techniques to alleviate pain.
- D. Encourage the patient to exercise and walk around to relieve discomfort.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdomen and back pain could be indicative of preterm labor. Therefore, the nurse's first priority should be to assess the patient for signs of preterm labor, such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. This is crucial to determine if the patient and the fetus are in any immediate danger. Administering pain medication (choice A), instructing relaxation techniques (choice C), or encouraging exercise (choice D) are not appropriate initial actions as they do not address the potential serious issue of preterm labor.
A pregnant patient at 26 weeks gestation reports dizziness and faintness when standing. Which intervention should the nurse prioritize?
- A. Encourage the patient to drink plenty of fluids and avoid standing for long periods.
- B. Instruct the patient to rise quickly from a seated position.
- C. Encourage the patient to lie flat on her back and rest.
- D. Advise the patient to take iron supplements to prevent dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink plenty of fluids and avoid standing for long periods. This intervention addresses the symptoms of dizziness and faintness by preventing dehydration and orthostatic hypotension common during pregnancy. Fluid intake maintains blood volume, reducing the risk of hypotension. Avoiding prolonged standing helps prevent blood pooling in the lower extremities. Choices B and C could exacerbate symptoms by causing sudden changes in blood pressure. Choice D is incorrect as iron supplements do not directly address the immediate issue of dizziness and faintness related to dehydration and orthostatic hypotension during pregnancy.
A pregnant patient is 26 weeks gestation and reports difficulty breathing when lying flat. What should the nurse recommend?
- A. Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm.
- B. Recommend sleeping in a fully reclined position to prevent shortness of breath.
- C. Administer oxygen as prescribed to ensure proper oxygenation.
- D. Instruct the patient to lie flat on her back and use a pillow for support.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm. At 26 weeks gestation, the uterus can compress the inferior vena cava when lying flat on the back, leading to decreased blood return to the heart and reduced cardiac output, causing difficulty breathing. Sleeping on the left side helps improve circulation by reducing pressure on the vena cava, enhancing blood flow and oxygenation to the fetus and mother.
Incorrect options:
B: Recommending sleeping in a fully reclined position may not alleviate the compression on the vena cava and could potentially worsen the patient's symptoms.
C: Administering oxygen may help with oxygenation but does not address the underlying issue of vena cava compression due to the growing uterus.
D: Instructing the patient to lie flat on her back can exacerbate the issue by further compressing the vena cava, worsening breathing difficulties.
During the third stage of labor, the nurse notes excessive bleeding. What should the nurse assess first?
- A. uterine tone
- B. placental separation
- C. vaginal bleeding
- D. cervical dilation
Correct Answer: A
Rationale: During the third stage of labor, the correct answer is A: uterine tone. This is because assessing uterine tone is crucial in determining if the uterus is contracting effectively to control bleeding. If the uterus is not firm (boggy), it can lead to postpartum hemorrhage. Placental separation (B) occurs during the third stage, but assessing uterine tone takes precedence. Vaginal bleeding (C) is a symptom of potential postpartum hemorrhage, which can be caused by poor uterine tone. Cervical dilation (D) is not a priority in this situation as the focus should be on controlling bleeding.