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A patient with gestational hypertension is being monitored during labor. What is the most important factor to assess?
- A. Fetal heart rate
- B. Blood pressure
- C. Uterine contractions
- D. Fetal malpresentation
Correct Answer: B
Rationale: The correct answer is B: Blood pressure. In a patient with gestational hypertension, monitoring blood pressure is crucial to assess for worsening hypertension, which can lead to complications such as preeclampsia and eclampsia. Elevated blood pressure can affect both maternal and fetal well-being. Assessing fetal heart rate (A) is important but not the most critical factor in this scenario. Uterine contractions (C) are important but secondary to monitoring blood pressure. Fetal malpresentation (D) can impact delivery but is not the most vital factor to assess in a patient with gestational hypertension.
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What organ does the ductus venosus shunt blood away from in fetal circulation?
- A. Liver
- B. Heart
- C. Lungs
- D. Kidneys
Correct Answer: A
Rationale: Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.
A nurse is caring for a laboring person who is experiencing strong contractions. What is the most important intervention to support the laboring person during this time?
- A. provide comfort measures
- B. assist with breathing exercises
- C. provide reassurance and comfort
- D. administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: provide comfort measures. Comfort measures such as massage, positioning, and relaxation techniques help the laboring person cope with the pain and intensity of contractions. By providing comfort, the nurse can help reduce stress and anxiety, promoting a more positive labor experience.
Choice B (assist with breathing exercises) can be helpful, but comfort measures are more essential for overall well-being during labor. Choice C (provide reassurance and comfort) is similar to the correct answer but lacks the specific action of providing comfort measures. Choice D (administer antibiotics) is irrelevant to the management of strong contractions and is not indicated unless there is a specific medical reason for antibiotics.
A nurse is assessing a 36-week pregnant patient who is complaining of sudden and severe headaches. What is the nurse's priority action?
- A. Encourage the patient to take a warm shower and rest.
- B. Assess the patient's blood pressure and check for signs of preeclampsia.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to drink more water to stay hydrated.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's blood pressure and check for signs of preeclampsia. Sudden and severe headaches in a pregnant patient could indicate preeclampsia, a serious condition characterized by high blood pressure. The nurse's priority is to assess for signs of preeclampsia to ensure the safety of both the mother and the baby. Encouraging rest or a warm shower, administering pain medication, or advising hydration do not address the potential underlying issue of preeclampsia and could delay necessary medical intervention.
A nurse is educating a pregnant patient about the signs of preterm labor. Which of the following should the nurse include in the teaching plan?
- A. Frequent, regular contractions every 10 minutes or less.
- B. Decreased fetal movement and back pain.
- C. Mild cramping and occasional vaginal spotting.
- D. Headaches and blurred vision, especially after physical activity.
Correct Answer: A
Rationale: The correct answer is A because frequent, regular contractions every 10 minutes or less are a classic sign of preterm labor, indicating the need for immediate medical attention. Decreased fetal movement and back pain (choice B) are not specific signs of preterm labor. Mild cramping and occasional vaginal spotting (choice C) could be normal in pregnancy or may indicate other issues, but they are not definitive signs of preterm labor. Headaches and blurred vision (choice D) are more indicative of preeclampsia, a separate condition from preterm labor. Therefore, choice A is the most accurate and specific sign to include in the teaching plan for preterm labor.
How should the nurse respond to a concern about alcohol exposure during conception?
- A. Inform the doctor
- B. Reassure it's unlikely the baby was affected
- C. Suggest abortion
- D. Recommend ultrasound
Correct Answer: B
Rationale: Occasional alcohol exposure around conception is unlikely to cause significant harm, though ongoing abstinence is advised.