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A patient in labor is at 6 cm dilation and requests an epidural. What is the most appropriate response from the nurse?
- A. You need to be at least 8 cm dilated for an epidural.
- B. You can have the epidural now since you are in active labor.
- C. The epidural can be administered after the second stage of labor.
- D. An epidural is only administered during the latent phase of labor.
Correct Answer: B
Rationale: The correct answer is B: "You can have the epidural now since you are in active labor." At 6cm dilation, the patient is typically considered to be in active labor, making it an appropriate time to offer an epidural for pain relief. Administering the epidural at this stage can help manage the pain effectively and provide relief during the remainder of labor. Other choices are incorrect because waiting until 8cm dilation (Choice A) may cause unnecessary suffering, administering after the second stage (Choice C) is too late for pain relief, and giving it during the latent phase (Choice D) is not ideal as the patient may not be in active labor yet.
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A pregnant patient is at 32 weeks gestation and reports a sudden headache and visual disturbances. What is the nurse's priority action?
- A. Encourage the patient to lie down and rest for a while.
- B. Assess the patient's blood pressure and check for protein in the urine.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to drink a caffeinated beverage to relieve symptoms.
Correct Answer: B
Rationale: The correct answer is B because sudden headache and visual disturbances in a pregnant patient at 32 weeks gestation could indicate preeclampsia. Assessing blood pressure and checking for protein in the urine are crucial steps in diagnosing preeclampsia, a serious condition that requires immediate medical attention to prevent complications for both the mother and baby. Encouraging rest, administering pain medication, or suggesting caffeinated beverages may mask symptoms but not address the underlying issue of preeclampsia. Therefore, prompt assessment and monitoring of blood pressure and urine protein levels are essential in this scenario.
The nurse is caring for a patient at 7 weeks gestation. The nurse suspects that a pregnant patient may have been using marijuana. With consent, the nurse confirms via urine drug screen. Which statement by the nurse is most appropriate?
- A. Did you smoke marijuana when pregnant with your other child?
- B. To avoid negative effects on your baby, you'll need to stop using marijuana during your last trimester.
- C. Using marijuana while pregnant can have a negative effect on the neurological development of your baby.
- D. Marijuana use while pregnant greatly increases your risk of miscarriage.
Correct Answer: C
Rationale: The correct answer is C: Using marijuana while pregnant can have a negative effect on the neurological development of your baby.
Rationale:
1. Marijuana use during pregnancy has been associated with adverse effects on the developing fetus, including potential negative impacts on neurological development.
2. The nurse's statement acknowledges the potential harm to the baby's neurological development, emphasizing the importance of avoiding marijuana during pregnancy.
3. This response focuses on providing essential information to the patient about the specific risks associated with marijuana use during pregnancy, highlighting the importance of making informed choices for the health of the baby.
Summary:
A: This choice makes assumptions about the patient's past behavior and does not provide essential information about the risks of marijuana use during pregnancy.
B: This choice focuses on the timing of stopping marijuana use rather than addressing the potential harm to the baby's neurological development.
D: This choice mentions miscarriage as a risk, which is not the primary concern associated with marijuana use during pregnancy.
The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination.
- A. Orthopneic.
- B. Lateral-recumbent.
- C. Sims'.
- D. Semi-Fowler’s.
Correct Answer: B
Rationale: The lateral-recumbent position reduces pressure on the inferior vena cava and is safer for pregnant women compared to other positions.
During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy?
- A. Dizygotic twins
- B. Monozygotic twins
- C. Conjoined twins
- D. High birth-weight twins
Correct Answer: A
Rationale: Dizygotic twins always have two amnions and two chorions (placentas).
A patient who is 40 weeks pregnant and is in labor suddenly complains of a severe headache and blurry vision. What should the nurse assess for?
- A. Preeclampsia
- B. Fetal distress
- C. Uterine rupture
- D. Placenta previa
Correct Answer: A
Rationale: The correct answer is A: Preeclampsia. In this scenario, the sudden onset of severe headache and blurry vision in a pregnant woman in labor are indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and signs of organ damage. The nurse should assess for other symptoms of preeclampsia such as hypertension, proteinuria, edema, and epigastric pain. Preeclampsia can lead to eclampsia, seizures, and life-threatening complications for both the mother and the baby if not promptly managed.
Summary:
B: Fetal distress - Not the priority assessment when the mother is experiencing symptoms indicative of a serious maternal condition like preeclampsia.
C: Uterine rupture - Symptoms are not suggestive of uterine rupture, which typically presents with severe abdominal pain, vaginal bleeding, and signs of shock.
D: Placenta previa - Symptoms are not consistent with placenta previa, which typically