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A nurse is preparing a laboring person for an epidural. What is the most important nursing action before the procedure?
- A. ensure informed consent is signed
- B. administer pain medication
- C. administer IV fluids
- D. administer an analgesic
Correct Answer: A
Rationale: The correct answer is A: ensure informed consent is signed. Before any procedure, obtaining informed consent is essential to ensure the laboring person understands the risks, benefits, and alternatives of the epidural. This helps promote autonomy and respect for the individual's decision-making. Administering pain medication (choice B), IV fluids (choice C), or an analgesic (choice D) without informed consent is not ethical and violates the principle of autonomy. The focus should be on providing comprehensive information and obtaining consent before proceeding with the intervention.
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A pregnant patient at 26 weeks gestation reports frequent headaches and blurred vision. What should the nurse do first?
- A. Encourage the patient to take over-the-counter pain medication for relief.
- B. Monitor the patient's blood pressure and check for signs of preeclampsia.
- C. Advise the patient to rest and stay hydrated to alleviate symptoms.
- D. Schedule a follow-up appointment for further evaluation in a few days.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure and check for signs of preeclampsia. At 26 weeks gestation, headaches and blurred vision could be symptoms of preeclampsia, a serious condition in pregnancy. Monitoring blood pressure is crucial as high blood pressure is a key indicator. Preeclampsia can lead to severe complications for both the mother and baby if left untreated. Encouraging over-the-counter pain medication (Choice A) may mask symptoms without addressing the underlying cause. Rest and hydration (Choice C) are important, but immediate evaluation for preeclampsia is necessary. Scheduling a follow-up appointment (Choice D) delays potential diagnosis and treatment.
The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods?
- A. Tofu, legumes, broccoli.
- B. Corn, yams, green beans.
- C. Potatoes, parsnips, turnips.
- D. Cheese, yogurt, fish.
Correct Answer: A
Rationale: Tofu, legumes, and broccoli provide essential nutrients like protein, iron, and calcium that are often lacking in a vegan diet. Corn, yams, and green beans offer carbohydrates and vitamins but lack sufficient protein sources. Potatoes, parsnips, and turnips are starchy vegetables with limited nutritional variety. Cheese, yogurt, and fish are non-vegan options.
A nurse is caring for a laboring person who is receiving oxytocin for labor induction. What is the priority intervention when uterine hyperstimulation occurs?
- A. stop the oxytocin infusion
- B. increase the oxytocin infusion
- C. administer IV fluids
- D. administer an epidural
Correct Answer: D
Rationale: The correct answer is D: administer an epidural. Uterine hyperstimulation during labor can lead to fetal distress and complications. Administering an epidural can help manage pain and relax the uterus, reducing the risk of hyperstimulation. Stopping the oxytocin infusion (choice A) is also important, but managing the uterine contractions with an epidural takes priority. Increasing the oxytocin infusion (choice B) would exacerbate the hyperstimulation. Administering IV fluids (choice C) may be helpful, but it does not directly address the uterine hyperstimulation.
A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of the following comments by the nurse is appropriate at this time?
- A. We expect you to gain about 1 lb per week, so your weight is a little low at this time.
- B. Most women gain no weight during the first trimester, so I would suggest you eat fewer desserts for the next few weeks.
- C. You entered the pregnancy well underweight, so we should check your diet to make sure you are getting the nutrients you need.
- D. Your weight gain is exactly what we would expect it to be at this time.
Correct Answer: D
Rationale: A weight gain of 3 to 5 lb is expected during the first trimester. The client's weight gain is within the normal range.
A nurse is caring for a pregnant patient who is 8 weeks gestation. The patient is asking about the safety of taking over-the-counter cold medications. Which response is most appropriate?
- A. It is safe to take any over-the-counter medication during pregnancy.
- B. You should only take medications that are specifically labeled for pregnancy use.
- C. Cold medications are never safe to take during pregnancy.
- D. Only herbal remedies are safe for treating colds during pregnancy.
Correct Answer: B
Rationale: The correct answer is B because during pregnancy, it is essential to be cautious about medications. Choosing medications specifically labeled for pregnancy ensures safety for both the mother and the developing fetus. Choice A is incorrect because not all over-the-counter medications are safe during pregnancy. Choice C is incorrect as some cold medications are safe when used as directed. Choice D is incorrect as not all herbal remedies are proven safe for use during pregnancy. It is important to prioritize the well-being of both the mother and the baby by following healthcare provider recommendations and using medications approved for use during pregnancy.