A pregnant patient at 24 weeks gestation reports feeling fatigued and lightheaded. What is the nurse's first priority action?
- A. Encourage the patient to rest and drink fluids.
- B. Monitor the patient's blood pressure and assess for signs of anemia.
- C. Administer iron supplements to alleviate fatigue.
- D. Instruct the patient to avoid any physical activity until symptoms subside.
Correct Answer: B
Rationale: The correct answer is B. Monitoring the patient's blood pressure and assessing for signs of anemia is the first priority because fatigue and lightheadedness in pregnancy can be symptoms of anemia or other serious conditions. Anemia can lead to complications for both the mother and the baby. Encouraging rest and fluids (choice A) is important but should come after ruling out any potential serious conditions. Administering iron supplements (choice C) without proper assessment can be harmful if anemia is not the cause. Instructing the patient to avoid physical activity (choice D) without proper evaluation can delay necessary interventions.
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What advice should the nurse give regarding herbal supplements during pregnancy?
- A. Herbals are safe because they're natural
- B. Licorice and cat’s claw are safe
- C. The FDA has approved herbals for pregnancy
- D. Discuss everything with a healthcare provider
Correct Answer: D
Rationale: Herbal supplements may pose risks during pregnancy, and their safety is not well-established. Consulting a healthcare provider is essential.
The nurse is caring for a 35-year-old woman who is pregnant and has a history of hypertension. Which intervention would be most important to prevent preeclampsia?
- A. Encourage regular physical activity and a healthy diet.
- B. Monitor the patient's weight gain and blood pressure.
- C. Prescribe antihypertensive medications immediately.
- D. Avoid any further prenatal visits to prevent stress.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's weight gain and blood pressure. Monitoring weight gain and blood pressure is crucial to detect early signs of preeclampsia in pregnant women with a history of hypertension. Weight gain can indicate fluid retention, a common symptom of preeclampsia, while high blood pressure is a key indicator of the condition. By closely monitoring these parameters, the nurse can promptly identify and manage preeclampsia to prevent complications for both the mother and the baby.
Incorrect choices:
A: Encouraging regular physical activity and a healthy diet is important for overall health but may not directly prevent preeclampsia.
C: Prescribing antihypertensive medications immediately may be necessary if blood pressure is severely elevated, but it is not the most important intervention for preventing preeclampsia.
D: Avoiding prenatal visits to prevent stress is not a valid approach as regular prenatal care is essential for monitoring the pregnancy and managing any complications that may
A nurse is educating a postpartum person about newborn care. Which of the following should be included in the teaching about umbilical cord care?
- A. keep the cord dry and clean
- B. apply a sterile dressing to the cord
- C. use alcohol or iodine to clean the cord
- D. apply a sterile dressing to the umbilicus
Correct Answer: A
Rationale: The correct answer is A: keep the cord dry and clean. This is because keeping the umbilical cord dry and clean helps prevent infection and promotes healing. Applying a sterile dressing (B) is unnecessary and may trap moisture, leading to infection. Using alcohol or iodine (C) is outdated and can delay cord separation. Applying a sterile dressing to the umbilicus (D) is not recommended as it can interfere with air circulation and healing. In summary, choice A is correct as it aligns with current best practices for umbilical cord care.
A pregnant patient is at 30 weeks gestation and is experiencing difficulty breathing, especially when lying flat. What is the nurse's priority action?
- A. Encourage the patient to rest in an upright position.
- B. Administer oxygen and prepare the patient for delivery.
- C. Monitor the fetal heart rate for signs of distress.
- D. Instruct the patient to take deep breaths and stay in bed.
Correct Answer: A
Rationale: The correct answer is A - Encourage the patient to rest in an upright position. This is the priority action because the patient is likely experiencing supine hypotensive syndrome due to pressure on the vena cava when lying flat. This can compromise blood flow to the fetus. By having the patient rest in an upright position, the pressure on the vena cava is reduced, improving blood flow and oxygenation for both the patient and the fetus. Administering oxygen and preparing for delivery (option B) is not the immediate priority. Monitoring fetal heart rate (option C) is important but not the initial action. Instructing the patient to take deep breaths and stay in bed (option D) does not address the underlying issue of supine hypotensive syndrome.
The nurse is interviewing a 38-week gestation Muslim woman.
- A. Do you plan to breastfeed your baby?
- B. What do you plan to name the baby?
- C. Which pediatrician do you plan to use?
- D. How do you feel about having an episiotomy?
Correct Answer: D
Rationale: Questions about episiotomy might be culturally sensitive or inappropriate without prior discussion of preferences, especially in certain cultural contexts like Islam.