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A pregnant patient at 28 weeks gestation is experiencing severe swelling in her hands and feet. Which of the following actions should the nurse take first?
- A. Assess the patient's blood pressure and check for signs of preeclampsia.
- B. Encourage the patient to elevate her legs and rest.
- C. Monitor the patient's urine output and report any changes.
- D. Schedule an ultrasound to assess fetal growth and amniotic fluid levels.
Correct Answer: A
Rationale: The correct action to take first is to assess the patient's blood pressure and check for signs of preeclampsia (Answer A). Preeclampsia is a serious condition characterized by high blood pressure and signs of organ dysfunction. In this scenario, the patient's severe swelling could be indicative of preeclampsia, which poses a risk to both the mother and the fetus. By assessing blood pressure and looking for other signs of preeclampsia, the nurse can determine the urgency of the situation and take appropriate actions to manage the condition.
Encouraging leg elevation and rest (Answer B) may help alleviate some symptoms but does not address the underlying cause of the swelling. Monitoring urine output (Answer C) is important for overall assessment but does not address the immediate concern of potential preeclampsia. Scheduling an ultrasound (Answer D) is not the priority in this situation as it does not provide information about the patient's current condition and does not address the
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A nurse is monitoring a postpartum person for signs of infection. Which finding would be most concerning in the first 24 hours after delivery?
- A. fever
- B. foul-smelling lochia
- C. increased blood pressure
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: fever. A fever in the first 24 hours after delivery is most concerning as it may indicate an infection, such as endometritis, which can lead to serious complications if not promptly treated. Postpartum fever is often the earliest sign of infection due to retained products of conception or ascending genital tract infection. Monitoring for fever is crucial as it can help prevent sepsis. Foul-smelling lochia (choice B) may suggest infection but is not as immediate a concern as fever. Increased blood pressure (choice C) and heart rate (choice D) may be normal physiological responses to delivery and are not specific indicators of infection in the immediate postpartum period.
A pregnant patient at 12 weeks gestation is asking about safe activities during pregnancy. Which of the following responses is most appropriate?
- A. You should avoid all physical activity to protect your baby.
- B. Moderate exercise, such as walking and swimming, is safe during pregnancy.
- C. You can engage in vigorous exercise, as long as you don't feel any discomfort.
- D. Only yoga and stretching exercises are safe during pregnancy.
Correct Answer: B
Rationale: The correct answer is B because moderate exercise like walking and swimming is generally safe during pregnancy and can provide health benefits for both the mother and the baby. Walking and swimming are low-impact activities that can help improve cardiovascular health, reduce stress, and enhance overall well-being without posing significant risks.
Option A is incorrect as physical activity is important during pregnancy, and avoiding all activity can be detrimental to both the mother and the baby. Option C is incorrect as engaging in vigorous exercise may increase the risk of injury or complications during pregnancy. Option D is incorrect as a variety of moderate exercises beyond just yoga and stretching can be safe and beneficial during pregnancy.
A woman in labor requests an epidural. What should the nurse assess before administering the epidural?
- A. Cervical dilation
- B. Maternal blood pressure
- C. Fetal heart rate
- D. Maternal temperature
Correct Answer: B
Rationale: The correct answer is B: Maternal blood pressure. Before administering an epidural, it is crucial to assess the maternal blood pressure to ensure it is within the normal range. Hypotension can occur as a common side effect of epidural anesthesia, which can lead to decreased placental perfusion and compromise fetal oxygenation. Assessing maternal blood pressure helps in preventing potential complications.
Incorrect choices:
A: Cervical dilation - Not directly related to the administration of an epidural.
C: Fetal heart rate - Important but not the immediate assessment needed before administering an epidural.
D: Maternal temperature - While it is important in general assessment, it is not specifically required before giving an epidural.
A woman in labor begins to experience severe lower abdominal pain and is found to have a ruptured uterus. What is the first intervention the nurse should perform?
- A. Administer intravenous fluids
- B. Prepare the patient for immediate surgery
- C. Perform a vaginal examination
- D. Administer pain relief medications
Correct Answer: B
Rationale: The correct answer is B: Prepare the patient for immediate surgery. In the case of a ruptured uterus, prompt surgical intervention is crucial to control bleeding, repair the uterus, and prevent further complications such as hemorrhage and infection. Performing surgery is the priority over other interventions like administering fluids, pain relief medications, or performing a vaginal examination, as these actions do not address the immediate life-threatening situation of uterine rupture. Administering IV fluids may be necessary during surgery, and pain relief can be addressed post-operatively. Vaginal examination is contraindicated in cases of suspected uterine rupture as it can exacerbate the bleeding and worsen the condition.
The nurse is caring for a pregnant patient who is 22 weeks gestation and has a history of gestational hypertension. What should the nurse monitor most closely?
- A. Blood glucose levels to check for gestational diabetes
- B. Protein in the urine to assess for preeclampsia
- C. Fetal heart rate to check for signs of fetal distress
- D. Daily weight gain to assess for fluid retention
Correct Answer: B
Rationale: The correct answer is B: Protein in the urine to assess for preeclampsia. The nurse should closely monitor protein in the urine because the patient has a history of gestational hypertension, which puts her at risk for developing preeclampsia. Preeclampsia is characterized by high blood pressure and proteinuria. Monitoring protein in the urine helps detect early signs of preeclampsia, which can lead to serious complications for both the mother and the fetus if left untreated.
Blood glucose levels (A) are not the priority in this case, as the patient's history indicates a higher risk for preeclampsia. Fetal heart rate (C) and daily weight gain (D) are important aspects to monitor during pregnancy; however, in this scenario, the focus should be on detecting signs of preeclampsia due to the patient's history of gestational hypertension.