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A nurse is preparing a laboring person for a cesarean birth. What is the priority action before the procedure?
- A. ensure informed consent is signed
- B. administer preoperative medication
- C. administer IV fluids
- D. administer a sedative
Correct Answer: C
Rationale: The correct answer is C: administer IV fluids. Before a cesarean birth, IV fluids are crucial to maintain hydration and prevent hypotension due to anesthesia. Administering IV fluids helps stabilize the person's blood pressure during the procedure, reducing the risk of complications. A is incorrect because informed consent should be obtained earlier in the process. B is incorrect as preoperative medication is typically given closer to the procedure start time. D is incorrect as administering a sedative may affect the person's ability to participate in decision-making and care during the procedure. Administering IV fluids is the priority to ensure the person's safety and well-being during the cesarean birth.
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The nurse is caring for a pregnant patient who is 22 weeks gestation and is concerned about her weight gain. Which of the following statements by the patient indicates the need for further teaching?
- A. I should aim to gain 1 to 2 pounds per week during my pregnancy.
- B. I will avoid eating extra food to prevent excessive weight gain.
- C. I can eat for two during my pregnancy to ensure the baby's growth.
- D. I will maintain a healthy diet and exercise regularly to support my pregnancy.
Correct Answer: C
Rationale: Correct Answer: C - "I can eat for two during my pregnancy to ensure the baby's growth."
Rationale:
1. Eating for two is a common misconception; the pregnant woman only needs an additional 300-500 calories per day.
2. Overeating can lead to excessive weight gain which may pose risks to both the mother and the baby.
3. The statement does not reflect an accurate understanding of healthy nutrition during pregnancy.
Summary of Incorrect Choices:
A: Choosing to gain 1 to 2 pounds per week aligns with healthy weight gain during pregnancy.
B: Avoiding excessive food intake is an appropriate strategy to prevent excessive weight gain.
D: Maintaining a healthy diet and regular exercise are essential for supporting a healthy pregnancy.
The patient who has received a dose of preservative-free morphine (Duramorph) is beginning to experience pruritus. Which medication is used to treat this?
- A. Low-dose naloxone infusion
- B. Diphenhydramine
- C. Dilaudid
- D. Sublimaze
Correct Answer: B
Rationale: The correct answer is B: Diphenhydramine. Pruritus is a common side effect of opioids like morphine. Diphenhydramine, an antihistamine, can help alleviate itching by blocking histamine receptors. Low-dose naloxone infusion (A) is used to reverse opioid overdose, not treat pruritus. Dilaudid (C) and Sublimaze (D) are also opioids and would not be effective in treating pruritus caused by morphine. Diphenhydramine is the most appropriate choice for addressing this specific symptom.
A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits?
- A. Leg cramps.
- B. Varicose veins.
- C. Hemorrhoids.
- D. Fainting spells.
Correct Answer: A
Rationale: Leg cramps, varicose veins, and hemorrhoids are common complaints during pregnancy due to increased blood volume and pressure on the lower extremities. Fainting spells are not considered normal and may indicate an underlying issue.
Where is the usual location for implantation of the zygote?
- A. Upper section of the posterior uterine wall
- B. Lower portion of the uterus near the cervical os
- C. Inner third of the fallopian tube near the uterus
- D. Lateral aspect of the uterine wall
Correct Answer: A
Rationale: The zygote usually implants in the upper section of the posterior uterine wall.
A pregnant patient is at 24 weeks gestation and reports occasional cramping and lower abdominal discomfort. What should the nurse do first?
- A. Assess for signs of preterm labor and monitor the patient for regular contractions.
- B. Administer pain medications and encourage the patient to rest.
- C. Perform a pelvic exam to assess for cervical changes.
- D. Instruct the patient to increase fluid intake and monitor the symptoms.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of preterm labor and monitor the patient for regular contractions. This is the most appropriate action as the patient is experiencing cramping and lower abdominal discomfort, which could indicate preterm labor. Step 1: Assessing for signs of preterm labor, such as regular contractions, is crucial to determine the patient's condition. Step 2: Monitoring the patient for regular contractions helps in identifying any patterns and assessing the progression of labor. Other choices are incorrect as B: Administering pain medications without assessing for preterm labor can mask important indicators. C: Performing a pelvic exam may increase the risk of infection and is not the priority. D: Instructing the patient to increase fluid intake may not address the potential risk of preterm labor.