Nokea
A pregnant patient at 26 weeks gestation reports frequent headaches and blurred vision. What should the nurse do first?
- A. Encourage the patient to take over-the-counter pain medication for relief.
- B. Monitor the patient's blood pressure and check for signs of preeclampsia.
- C. Advise the patient to rest and stay hydrated to alleviate symptoms.
- D. Schedule a follow-up appointment for further evaluation in a few days.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure and check for signs of preeclampsia. At 26 weeks gestation, headaches and blurred vision could be symptoms of preeclampsia, a serious condition in pregnancy. Monitoring blood pressure is crucial as high blood pressure is a key indicator. Preeclampsia can lead to severe complications for both the mother and baby if left untreated. Encouraging over-the-counter pain medication (Choice A) may mask symptoms without addressing the underlying cause. Rest and hydration (Choice C) are important, but immediate evaluation for preeclampsia is necessary. Scheduling a follow-up appointment (Choice D) delays potential diagnosis and treatment.
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A nurse is preparing a laboring person for an epidural. What is the most important nursing action before the procedure?
- A. ensure informed consent is signed
- B. administer pain medication
- C. administer IV fluids
- D. administer an analgesic
Correct Answer: A
Rationale: The correct answer is A: ensure informed consent is signed. Before any procedure, obtaining informed consent is essential to ensure the laboring person understands the risks, benefits, and alternatives of the epidural. This helps promote autonomy and respect for the individual's decision-making. Administering pain medication (choice B), IV fluids (choice C), or an analgesic (choice D) without informed consent is not ethical and violates the principle of autonomy. The focus should be on providing comprehensive information and obtaining consent before proceeding with the intervention.
A nurse is caring for a postpartum person who is breastfeeding. What is the most important intervention to prevent nipple trauma?
- A. assist with breastfeeding positioning
- B. offer pain relief
- C. apply a cold compress
- D. monitor contractions
Correct Answer: B
Rationale: The correct answer is B: offer pain relief. Providing pain relief is crucial in preventing nipple trauma as it can help the postpartum person tolerate any discomfort associated with breastfeeding, thereby reducing the likelihood of damage to the nipples. Assisting with breastfeeding positioning (choice A) is important but not as critical as pain relief. Applying a cold compress (choice C) may help with inflammation but does not directly address the pain during breastfeeding. Monitoring contractions (choice D) is unrelated to preventing nipple trauma. Ultimately, addressing pain relief is the most effective intervention in ensuring successful and comfortable breastfeeding, thus preventing nipple trauma.
What is the primary purpose of performing a vaginal examination during labor?
- A. to assess cervical dilation and effacement
- B. to assess fetal well-being and progress of labor
- C. to identify fetal distress
- D. to assess fetal descent and station
Correct Answer: B
Rationale: The correct answer is B because the primary purpose of performing a vaginal examination during labor is to assess fetal well-being and progress of labor. By conducting a vaginal exam, healthcare providers can monitor the fetal heart rate, position, and stage of labor. This information helps determine if the labor is progressing normally and if any interventions are needed. Choice A is incorrect because cervical dilation and effacement can be assessed but are not the primary purpose. Choice C is incorrect as fetal distress is typically identified through other methods such as continuous fetal monitoring. Choice D is incorrect as assessing fetal descent and station can be done through vaginal examination but is not the primary purpose.
What complication is associated with pica during pregnancy?
- A. Hypothyroidism
- B. Iron-deficiency anemia
- C. Hypercalcemia
- D. Overexposure to zinc
Correct Answer: B
Rationale: Pica often leads to nutritional deficiencies, particularly iron-deficiency anemia, due to the ingestion of non-food substances.
A pregnant patient at 36 weeks gestation reports difficulty breathing when lying flat. What should the nurse do first?
- A. Encourage the patient to rest in a semi-reclined position or on her left side.
- B. Administer oxygen as prescribed to improve oxygenation.
- C. Monitor the fetal heart rate and assess for signs of distress.
- D. Instruct the patient to take shallow breaths and stay in bed.
Correct Answer: A
Rationale: The correct answer is A because positioning the patient in a semi-reclined or left side position can alleviate pressure on the diaphragm and improve breathing. This position helps optimize blood flow to the uterus and placenta. Encouraging rest in this position can improve oxygenation for both the mother and fetus. Administering oxygen (Choice B) may help with oxygenation but does not address the underlying issue of positional discomfort. Monitoring fetal heart rate (Choice C) is important but not the first action to address the mother's breathing difficulty. Instructing the patient to take shallow breaths and stay in bed (Choice D) does not address the positional component of the issue.