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A nurse is providing discharge instructions to a postpartum person who had a cesarean birth. What is the most important instruction to include?
- A. avoid heavy lifting
- B. encourage deep breathing exercises
- C. encourage early ambulation
- D. avoid sexual activity
Correct Answer: B
Rationale: The correct answer is B: encourage deep breathing exercises. Deep breathing helps prevent complications like pneumonia after surgery, aids in lung expansion, and promotes overall respiratory health. Choice A is important but not the most crucial post-cesarean. Choice C promotes mobility but doesn't address immediate respiratory needs. Choice D is important but not the most vital in the early postpartum period.
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A woman states that she frequently awakens with 'painful leg cramps' during the night. Which of the following assessments should the nurse make?
- A. Dietary evaluation.
- B. Goodell’s sign.
- C. Hegar’s sign.
- D. Posture evaluation.
Correct Answer: A
Rationale: Leg cramps during pregnancy are often related to dietary deficiencies, particularly calcium and magnesium. A dietary evaluation is the most appropriate assessment.
The nurse is caring for a pregnant patient who is at 30 weeks gestation and is diagnosed with preterm labor. What intervention is the nurse likely to implement first?
- A. Administering corticosteroids to enhance fetal lung maturity
- B. Administering magnesium sulfate to prevent seizures
- C. Administering antibiotics to prevent infection
- D. Starting a medication to stop the contractions
Correct Answer: A
Rationale: The correct answer is A: Administering corticosteroids to enhance fetal lung maturity. Administering corticosteroids is the priority intervention in preterm labor at 30 weeks gestation as it helps accelerate fetal lung maturity, reducing the risk of respiratory distress syndrome. This intervention is crucial in improving neonatal outcomes. Administering magnesium sulfate (Choice B) is used to prevent seizures in preeclampsia, not preterm labor. Administering antibiotics (Choice C) is not the priority in preterm labor unless there is evidence of infection. Starting a medication to stop contractions (Choice D) may be necessary, but enhancing fetal lung maturity takes precedence to improve the baby's respiratory status.
The nurse working in an outpatient obstetric office assesses four primigravid clients. Which of the client findings should the nurse highlight for the physician? Select all that apply.
- A. 17 weeks’ gestation; denies feeling fetal movement.
- B. 24 weeks’ gestation; fundal height at the umbilicus.
- C. 27 weeks’ gestation; salivates excessively.
- D. 34 weeks’ gestation; experiences uterine cramping.
Correct Answer: A
Rationale: Denial of fetal movement at 17 weeks and uterine cramping at 34 weeks are concerning findings that should be highlighted for further evaluation. Fundal height at the umbilicus at 24 weeks and excessive salivation at 27 weeks are within normal limits.
The nurse is caring for a pregnant patient who is at 25 weeks gestation and is concerned about gestational diabetes. Which of the following symptoms should the nurse educate the patient to watch for?
- A. Increased thirst and frequent urination
- B. Severe leg cramps and dizziness
- C. Constant fatigue and swollen feet
- D. Shortness of breath and dizziness upon standing
Correct Answer: A
Rationale: The correct answer is A: Increased thirst and frequent urination. These symptoms are indicative of gestational diabetes due to elevated blood sugar levels. Increased thirst is a result of the body trying to dilute the excess glucose through increased fluid intake, leading to frequent urination. This occurs because the kidneys work to eliminate the excess glucose from the blood by excreting it in the urine. Therefore, educating the patient to watch for these symptoms is crucial for early detection and management of gestational diabetes.
Choices B, C, and D are incorrect as they do not directly correlate with the symptoms of gestational diabetes. Severe leg cramps and dizziness (Choice B) may be related to other factors such as dehydration or electrolyte imbalance. Constant fatigue and swollen feet (Choice C) could be common symptoms during pregnancy but are not specific to gestational diabetes. Shortness of breath and dizziness upon standing (Choice D) are more likely to be related to issues such as anemia or changes
A laboring person is requesting an epidural for pain relief. What is the most important nursing action before the procedure?
- A. administer an epidural bolus
- B. check for any contraindications
- C. perform a vaginal exam
- D. ensure continuous fetal monitoring
Correct Answer: B
Rationale: The correct answer is B: check for any contraindications. Before administering an epidural, it is crucial to assess for contraindications such as low platelet count, infection at the insertion site, or severe hypotension as these may increase the risk of complications. Administering an epidural bolus (A) without checking for contraindications can be dangerous. Performing a vaginal exam (C) is not necessary before an epidural and could increase the risk of infection. Ensuring continuous fetal monitoring (D) is important during labor but is not the most critical action before administering an epidural.