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A postpartum person is experiencing a headache after delivery. What is the most appropriate initial nursing action?
- A. administer pain medication
- B. monitor blood pressure
- C. perform a neurological assessment
- D. provide oxygen to the person
Correct Answer: B
Rationale: The correct initial action is to monitor blood pressure (B) because postpartum headache could indicate preeclampsia, a serious condition characterized by high blood pressure. Monitoring blood pressure is crucial to assess for signs of preeclampsia. Administering pain medication (A) may mask symptoms, performing a neurological assessment (C) may not address the underlying cause, and providing oxygen (D) is not the priority without knowing the cause of the headache.
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A nurse is educating a pregnant patient who is at 30 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is safe and beneficial for pregnant women at 30 weeks gestation. Moderate exercise helps maintain health, improves circulation, reduces stress, and prepares the body for labor. Strenuous exercise (A) can be risky and may lead to complications. Avoiding all physical activity (C) can result in deconditioning and potential complications. High-impact exercises (D) can be too intense and pose a risk of injury during pregnancy. Prioritizing moderate exercise aligns with current guidelines for safe physical activity during pregnancy.
A 30-year-old pregnant patient is at 36 weeks gestation and expresses concerns about swelling in her legs. Which of the following assessments is most important for the nurse to make?
- A. Assess the patient's weight gain during the pregnancy.
- B. Examine the legs for any signs of deep vein thrombosis (DVT).
- C. Instruct the patient to elevate her legs and rest.
- D. Evaluate the patient's dietary intake of sodium.
Correct Answer: B
Rationale: The correct answer is B: Examine the legs for any signs of deep vein thrombosis (DVT). At 36 weeks gestation, pregnant women are at higher risk for DVT due to increased blood volume and pressure on the veins from the growing uterus. DVT can be life-threatening if not detected early. Assessing for any signs of DVT such as redness, warmth, swelling, or pain in the legs is crucial for prompt intervention.
Incorrect choices:
A: Assessing weight gain is important but not the priority in this situation where DVT is a concern.
C: Instructing the patient to elevate her legs and rest can help with swelling but does not address the potential serious complication of DVT.
D: Evaluating dietary intake of sodium is not the priority in this situation where DVT is a concern.
A client who was seen in the prenatal clinic at 20 weeks’ gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks’ gestation?
- A. 129 to 130 lb.
- B. 131 to 132 lb.
- C. 133 to 134 lb.
- D. 135 to 136 lb.
Correct Answer: C
Rationale: A weight gain of 1 lb per week is expected during the second and third trimesters. Therefore, the client should gain approximately 4 lb between 20 and 24 weeks.
A biophysical profile is performed on a pregnant patient. The results show a nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of the hand indicating the presence of fetal tone, and adequate amniotic fluid index (AFI). What is the correct interpretation of this test result?
- A. A score of 10 would indicate that the results are equivocal.
- B. A score of 8 would indicate normal results.
- C. A score of 6 would indicate that birth should be considered as a possible treatment option.
- D. A score of 9 would indicate reassurance.
Correct Answer: B
Rationale: A biophysical profile score of 8-10 is considered normal, indicating fetal well-being.
A 38-week pregnant patient in active labor is experiencing frequent and painful contractions. What is the most appropriate action for the nurse?
- A. Administer narcotic analgesics for pain relief
- B. Provide emotional support and reassurance
- C. Assess the fetal heart rate and contraction patterns
- D. Prepare for delivery
Correct Answer: D
Rationale: The correct answer is D: Prepare for delivery. At 38 weeks of gestation and in active labor, the most appropriate action is to prepare for delivery as the patient is likely to be close to giving birth. This involves ensuring that all necessary equipment and supplies are ready, notifying the healthcare team, and positioning the patient for delivery. Administering narcotic analgesics (choice A) may not be ideal at this stage as the priority is the imminent delivery. While emotional support and reassurance (choice B) are important, they should be provided alongside preparing for delivery. Assessing the fetal heart rate and contraction patterns (choice C) is crucial but should be done concurrently with preparing for delivery to ensure the safety of both the mother and baby.