Nokea
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.
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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.
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.
At what point in prenatal development do the lungs begin to produce surfactant?
- A. 17 weeks
- B. 20 weeks
- C. 25 weeks
- D. 30 weeks
Correct Answer: C
Rationale: During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur.
A nurse is caring for a postpartum person who is at risk for hemorrhage. What is the most appropriate action to prevent postpartum hemorrhage?
- A. monitor vital signs
- B. administer uterotonic medications
- C. assess uterine tone
- D. perform fundal massage
Correct Answer: B
Rationale: The correct answer is B: administer uterotonic medications. Administering uterotonic medications helps prevent postpartum hemorrhage by promoting uterine contractions, which helps to control bleeding. The step-by-step rationale for this answer is as follows: 1. Uterotonic medications, such as oxytocin or misoprostol, are recommended as a prophylactic measure to prevent postpartum hemorrhage. 2. These medications help the uterus to contract, which compresses blood vessels and reduces the risk of excessive bleeding. 3. Administering uterotonic medications is a proactive approach to managing postpartum hemorrhage in high-risk individuals. Summary: Monitoring vital signs (choice A) is important but does not directly prevent hemorrhage. Assessing uterine tone (choice C) is helpful but may not be sufficient in preventing hemorrhage. Performing fundal massage (choice D) can help manage hemorrhage but is not as effective as administering ut
A nurse is caring for a postpartum person who is breastfeeding. What is the most important intervention to prevent nipple trauma?
- A. assist with breastfeeding positioning
- B. offer pain relief
- C. apply a cold compress
- D. monitor contractions
Correct Answer: B
Rationale: The correct answer is B: offer pain relief. Providing pain relief is crucial in preventing nipple trauma as it can help the postpartum person tolerate any discomfort associated with breastfeeding, thereby reducing the likelihood of damage to the nipples. Assisting with breastfeeding positioning (choice A) is important but not as critical as pain relief. Applying a cold compress (choice C) may help with inflammation but does not directly address the pain during breastfeeding. Monitoring contractions (choice D) is unrelated to preventing nipple trauma. Ultimately, addressing pain relief is the most effective intervention in ensuring successful and comfortable breastfeeding, thus preventing nipple trauma.