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A nurse is educating a pregnant patient about the signs of preterm labor. Which of the following should the nurse include in the teaching plan?
- A. Frequent, regular contractions every 10 minutes or less.
- B. Decreased fetal movement and back pain.
- C. Mild cramping and occasional vaginal spotting.
- D. Headaches and blurred vision, especially after physical activity.
Correct Answer: A
Rationale: The correct answer is A because frequent, regular contractions every 10 minutes or less are a classic sign of preterm labor, indicating the need for immediate medical attention. Decreased fetal movement and back pain (choice B) are not specific signs of preterm labor. Mild cramping and occasional vaginal spotting (choice C) could be normal in pregnancy or may indicate other issues, but they are not definitive signs of preterm labor. Headaches and blurred vision (choice D) are more indicative of preeclampsia, a separate condition from preterm labor. Therefore, choice A is the most accurate and specific sign to include in the teaching plan for preterm labor.
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A pregnant woman who is 24 weeks gestation is experiencing excessive vomiting and dehydration. Which of the following interventions should the nurse prioritize?
- A. Administer an antiemetic to control vomiting.
- B. Encourage the patient to rest and avoid moving too much.
- C. Start intravenous fluids to restore hydration and electrolytes.
- D. Recommend that the patient eat smaller, more frequent meals.
Correct Answer: C
Rationale: The correct answer is C, starting intravenous fluids to restore hydration and electrolytes. This is the priority intervention because dehydration during pregnancy can lead to serious complications for both the mother and the baby. By administering IV fluids, the nurse can quickly rehydrate the mother and replenish electrolytes to ensure the well-being of both.
Choice A (Administer an antiemetic) may help control vomiting, but addressing dehydration is the primary concern. Choice B (Encourage rest) is important, but without addressing hydration first, rest alone will not resolve the issue. Choice D (Recommend smaller meals) may be helpful in managing nausea, but it does not address the immediate need for hydration and electrolyte balance.
A pregnant patient has received the results of her triple-screen testing and it is positive. What would the nurse anticipate as the next step in the patient’s plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: A positive triple-screen test suggests an increased risk of genetic abnormalities, requiring additional diagnostic testing.
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. administer pain relief
- C. administer analgesics
- D. perform perineal massage
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent the baby from being born too quickly, reducing the risk of tearing for the mother. It also ensures a controlled delivery, decreasing the likelihood of complications such as shoulder dystocia. Administering pain relief (B) or analgesics (C) may be necessary but not the most crucial at this moment. Performing perineal massage (D) is beneficial for reducing the risk of tearing but is not as important as guiding the baby's head during crowning.
A patient with gestational hypertension is being monitored during labor. What is the most important factor to assess?
- A. Fetal heart rate
- B. Blood pressure
- C. Uterine contractions
- D. Fetal malpresentation
Correct Answer: B
Rationale: The correct answer is B: Blood pressure. In a patient with gestational hypertension, monitoring blood pressure is crucial to assess for worsening hypertension, which can lead to complications such as preeclampsia and eclampsia. Elevated blood pressure can affect both maternal and fetal well-being. Assessing fetal heart rate (A) is important but not the most critical factor in this scenario. Uterine contractions (C) are important but secondary to monitoring blood pressure. Fetal malpresentation (D) can impact delivery but is not the most vital factor to assess in a patient with gestational hypertension.
A 34-week gestation woman calls the obstetric office stating, 'Since last night I have had three nosebleeds.'
- A. You should see the doctor to make sure you are not becoming severely anemic.
- B. Do you have a temperature?
- C. One of the hormones of pregnancy makes the nasal passages prone to bleeds.
- D. Do you use any inhaled drugs?
Correct Answer: C
Rationale: Pregnancy hormones increase blood supply to mucous membranes, making them more prone to bleeding. Nosebleeds are generally harmless unless associated with other symptoms.