Maternal Monitoring During Labor

Maternal Monitoring During Labor Related

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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

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A nurse is caring for a postpartum person who is at risk for postpartum hemorrhage. What is the most important nursing action to reduce the risk?

  • A. administer oxytocin
  • B. administer IV fluids
  • C. administer an epidural
  • D. perform fundal massage
Correct Answer: B

Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate circulating volume, preventing hypovolemia which is a major risk factor for postpartum hemorrhage. This action supports blood pressure and perfusion to reduce the risk of excessive bleeding. Administering oxytocin (A) helps with uterine contraction but does not address the underlying issue of hypovolemia. Administering an epidural (C) is not directly related to preventing postpartum hemorrhage. Fundal massage (D) is important but not the most critical action in reducing the risk of postpartum hemorrhage.

A pregnant patient at 32 weeks gestation reports persistent nausea and vomiting. What is the nurse's priority action?

  • A. Instruct the patient to take over-the-counter anti-nausea medication.
  • B. Monitor the patient's hydration status and assess for signs of dehydration.
  • C. Encourage the patient to eat large meals more frequently to prevent nausea.
  • D. Recommend the patient avoid drinking fluids to prevent further vomiting.
Correct Answer: B

Rationale: The correct answer is B: Monitor the patient's hydration status and assess for signs of dehydration. This is the priority action because nausea and vomiting during pregnancy can lead to dehydration, which can have serious consequences for both the mother and the baby. By monitoring the patient's hydration status and assessing for signs of dehydration, the nurse can ensure early intervention if dehydration occurs.

Incorrect choices:
A: Instruct the patient to take over-the-counter anti-nausea medication - This is not the priority as dehydration needs to be addressed first.
C: Encourage the patient to eat large meals more frequently to prevent nausea - This may exacerbate the nausea and vomiting, leading to further dehydration.
D: Recommend the patient avoid drinking fluids to prevent further vomiting - Dehydration can worsen if the patient avoids fluids.

The nurse takes the history of a client, G2 P1001, at her first prenatal visit. Which of the following statements would indicate that the client should be referred to a genetic counselor?

  • A. My first child has cerebral palsy.
  • B. My first child has hypertension.
  • C. My first child has asthma.
  • D. My first child has cystic fibrosis.
Correct Answer: D

Rationale: Cystic fibrosis is a genetic condition, and a history of it in a previous child would warrant a referral to a genetic counselor. Cerebral palsy, hypertension, and asthma are not typically genetic conditions.

What response is appropriate regarding sushi consumption during pregnancy?

  • A. Fish is healthy
  • B. Sushi is too salty
  • C. Raw fish is high in mercury
  • D. Fish should be cooked
Correct Answer: D

Rationale: Cooking fish destroys harmful bacteria and parasites, reducing the risk of foodborne illnesses during pregnancy.

A woman provides the nurse with the following obstetrical history: Delivered a son, now 7 years old, at 28 weeks’ gestation; delivered a daughter, now 5 years old, at 39 weeks’ gestation; had a miscarriage 3 years ago, and had a first-trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman’s gravidity and parity?

  • A. G4 P2121.
  • B. G4 P1212.
  • C. G5 P1122.
  • D. G5 P2211.
Correct Answer: D

Rationale: Gravidity includes all pregnancies (live births, miscarriages, abortions, and current pregnancy). Parity reflects live births. This woman has had 5 pregnancies (2 live births, 1 miscarriage, 1 abortion, and 1 current pregnancy), making her G5 P2211.

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