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A pregnant patient at 26 weeks gestation reports dizziness and faintness when standing. Which intervention should the nurse prioritize?
- A. Encourage the patient to drink plenty of fluids and avoid standing for long periods.
- B. Instruct the patient to rise quickly from a seated position.
- C. Encourage the patient to lie flat on her back and rest.
- D. Advise the patient to take iron supplements to prevent dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink plenty of fluids and avoid standing for long periods. This intervention addresses the symptoms of dizziness and faintness by preventing dehydration and orthostatic hypotension common during pregnancy. Fluid intake maintains blood volume, reducing the risk of hypotension. Avoiding prolonged standing helps prevent blood pooling in the lower extremities. Choices B and C could exacerbate symptoms by causing sudden changes in blood pressure. Choice D is incorrect as iron supplements do not directly address the immediate issue of dizziness and faintness related to dehydration and orthostatic hypotension during pregnancy.
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During the third stage of labor, the nurse notes excessive bleeding. What should the nurse assess first?
- A. uterine tone
- B. placental separation
- C. vaginal bleeding
- D. cervical dilation
Correct Answer: A
Rationale: During the third stage of labor, the correct answer is A: uterine tone. This is because assessing uterine tone is crucial in determining if the uterus is contracting effectively to control bleeding. If the uterus is not firm (boggy), it can lead to postpartum hemorrhage. Placental separation (B) occurs during the third stage, but assessing uterine tone takes precedence. Vaginal bleeding (C) is a symptom of potential postpartum hemorrhage, which can be caused by poor uterine tone. Cervical dilation (D) is not a priority in this situation as the focus should be on controlling bleeding.
A pregnant woman in her second trimester asks the nurse about taking herbal supplements to alleviate nausea. Which of the following is the nurse's best response?
- A. It is safe to take any herbal supplement during pregnancy.
- B. Some herbal supplements may cause harm to your pregnancy, and it's best to consult your doctor.
- C. Only certain over-the-counter medications are safe, not herbal supplements.
- D. Herbal supplements are more effective than prescription medications for nausea.
Correct Answer: B
Rationale: The correct answer is B because herbal supplements can vary in safety during pregnancy. It is always recommended to consult a healthcare provider before taking any supplements, as some herbs may potentially harm the pregnancy or interact with other medications. Answer A is incorrect as not all herbal supplements are safe during pregnancy. Answer C is incorrect as some herbal supplements may be safe if recommended by a healthcare provider. Answer D is incorrect as prescription medications are often more rigorously tested and regulated for safety during pregnancy compared to herbal supplements.
A nurse is preparing a laboring person for an emergency cesarean birth. What is the most important nursing intervention prior to the procedure?
- A. administer a preoperative medication
- B. administer pain relief
- C. administer an epidural block
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: administer a preoperative medication. This is crucial prior to an emergency cesarean birth to ensure the person is adequately prepared for the procedure. Preoperative medications can help reduce anxiety, prevent complications such as aspiration during anesthesia induction, and promote smooth recovery post-surgery. Administering pain relief (B) and epidural block (C) may be important for comfort but are not the priority in this urgent situation. Administering IV fluids (D) is generally important in preparation for surgery, but administering preoperative medication takes precedence in this scenario to ensure the person's safety and well-being during the emergency cesarean birth.
A 32-week pregnant woman is admitted to the hospital in preterm labor. What is the most appropriate intervention to delay delivery?
- A. Administer corticosteroids to promote fetal lung development
- B. Provide an epidural for pain management
- C. Give magnesium sulfate to inhibit uterine contractions
- D. Begin oxytocin infusion to speed up labor
Correct Answer: C
Rationale: The correct answer is C: Give magnesium sulfate to inhibit uterine contractions. Magnesium sulfate is used to delay preterm labor by relaxing the uterine muscles, thus decreasing contractions. This intervention helps to delay delivery and give time for other interventions to be implemented, such as administering corticosteroids to promote fetal lung development. Providing an epidural for pain management (B) does not address the issue of preterm labor. Beginning oxytocin infusion (D) would speed up labor, which is not appropriate in this scenario. Administering corticosteroids (A) is a beneficial intervention but should be done after delaying delivery with magnesium sulfate.
A nurse is caring for a laboring person who is receiving oxytocin for induction of labor. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate continuously
- B. increase maternal hydration
- C. administer IV fluids
- D. assess uterine tone
Correct Answer: C
Rationale: The correct answer is C because administering IV fluids is crucial during oxytocin infusion to prevent maternal dehydration and maintain fluid balance. This helps prevent complications such as uterine hyperstimulation and fetal distress. Monitoring fetal heart rate continuously (choice A) is important but not the priority. Increasing maternal hydration (choice B) is beneficial but does not address the immediate need for fluid replacement. Assessing uterine tone (choice D) is important but secondary to ensuring adequate hydration.