A nurse is preparing to administer a medication to a birthing person with a history of hypertension. What is the nurse's priority assessment before administering this medication?
- A. Blood pressure and pulse rate
- B. Respiratory rate and oxygen saturation
- C. Temperature and urine output
- D. Oxygen saturation and urine output
Correct Answer: A
Rationale: The correct answer is A: Blood pressure and pulse rate. For a birthing person with a history of hypertension, it is crucial to assess their blood pressure and pulse rate before administering medication to ensure the medication does not exacerbate their hypertension. Monitoring these vital signs helps in determining the appropriateness and safety of the medication.
Summary:
- Choice B is incorrect because respiratory rate and oxygen saturation are not the priority assessments for a person with a history of hypertension.
- Choice C is incorrect as temperature and urine output are not directly related to assessing the risk of exacerbating hypertension.
- Choice D is incorrect as oxygen saturation and urine output are not the primary indicators of medication safety for someone with hypertension.
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The nurse is caring for a pregnant patient at 32 weeks gestation who reports feeling lightheaded and faint when standing. What should the nurse recommend?
- A. Increase fluid intake and avoid standing for long periods.
- B. Take deep breaths and rise quickly from a seated position.
- C. Rest and avoid any physical activity during the day.
- D. Sit upright and avoid bending forward at the waist.
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake and avoid standing for long periods. This recommendation is appropriate for the patient's symptoms of lightheadedness and fainting, which could be due to dehydration or low blood pressure common in pregnancy. Increasing fluid intake can help maintain adequate blood volume and pressure. Avoiding prolonged standing can prevent pooling of blood in the lower extremities, reducing the risk of dizziness.
Choices B, C, and D are incorrect:
B: Taking deep breaths and rising quickly may worsen symptoms by causing a sudden drop in blood pressure.
C: Complete rest and avoiding physical activity may not address the underlying issue of hydration or blood pressure.
D: Sitting upright and avoiding bending forward may not directly address the need for increased fluid intake and reduced standing time.
The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not?
- A. 10%
- B. 25%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and is experiencing a sudden increase in vaginal discharge. What is the nurse's priority action?
- A. Check for signs of labor and assess fetal heart rate.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Perform a pelvic exam to assess the amount of discharge.
- D. Call the healthcare provider immediately to report the change in discharge.
Correct Answer: A
Rationale: The correct answer is A because the sudden increase in vaginal discharge at 40 weeks gestation could indicate the onset of labor. Checking for signs of labor, such as contractions and assessing fetal heart rate, is crucial to determine if the patient is in active labor. This helps in timely intervention and ensuring the well-being of both the mother and baby.
Summary:
- Choice B: Encouraging rest and monitoring changes in discharge may not address the urgency of the situation.
- Choice C: Performing a pelvic exam without assessing signs of labor or fetal well-being may delay necessary actions.
- Choice D: While reporting to the healthcare provider is important, immediate assessment of labor signs and fetal heart rate takes precedence.
A pregnant patient is 30 weeks gestation and is concerned about gestational hypertension. Which of the following is a key sign of gestational hypertension?
- A. Severe headache and visual changes
- B. Sudden swelling of the hands and feet
- C. Excessive weight loss and fatigue
- D. Frequent urination and dehydration
Correct Answer: B
Rationale: The correct answer is B: Sudden swelling of the hands and feet. Gestational hypertension is characterized by sudden onset of high blood pressure after 20 weeks of pregnancy, leading to fluid retention and swelling. This is known as preeclampsia, a severe form of gestational hypertension. Swelling in the hands and feet is a key sign due to fluid imbalance. Severe headache and visual changes (choice A) are more indicative of preeclampsia complications. Excessive weight loss and fatigue (choice C) are not typical signs of gestational hypertension. Frequent urination and dehydration (choice D) are not directly related to gestational hypertension.
A client makes the following statement after finding out that her pregnancy test is positive, 'This is not a good time. I am in college and the baby will be due during final exams!' Which of the following responses by the nurse would be most appropriate at this time?
- A. I’m absolutely positive that everything will turn out all right.
- B. I suggest that you e-mail your professors to set up an alternate plan.
- C. It sounds like you’re feeling a little overwhelmed right now.
- D. You and the baby’s father will find a way to get through the pregnancy.
Correct Answer: C
Rationale: Acknowledging the client's feelings of being overwhelmed is the most supportive response. Offering solutions or reassurance without first addressing the client's emotions may not be as effective.