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A pregnant patient at 32 weeks gestation reports a sudden headache and blurred vision. What is the nurse's priority action?
- A. Assess the patient's blood pressure and check for signs of preeclampsia.
- B. Administer pain medication and advise the patient to rest.
- C. Encourage the patient to drink fluids and take deep breaths.
- D. Perform a visual acuity test and schedule a follow-up appointment.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's blood pressure and check for signs of preeclampsia. This is the priority action because sudden headache and blurred vision are symptoms of preeclampsia, a serious condition in pregnancy. Step 1: Assessing blood pressure is crucial to identify hypertension, a hallmark of preeclampsia. Step 2: Checking for other signs of preeclampsia, such as proteinuria and edema, helps confirm the diagnosis. Step 3: Prompt intervention is necessary to prevent complications for both the mother and the baby. Choices B, C, and D are incorrect because they do not address the potential life-threatening condition of preeclampsia and may delay appropriate treatment.
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Which of the following vital sign changes should the nurse highlight for a pregnant woman’s obstetrician?
- A. Prepregnancy blood pressure (BP) 100/60 and third trimester BP 140/90.
- B. Prepregnancy respiratory rate (RR) 16 rpm and third trimester RR 22 rpm.
- C. Prepregnancy heart rate (HR) 76 bpm and third trimester HR 88 bpm.
- D. Prepregnancy temperature (T) 98.6°F and third trimester T 99.2°F.
Correct Answer: A
Rationale: A significant increase in blood pressure, particularly to 140/90, could indicate preeclampsia and should be highlighted for further evaluation. The other changes are within normal limits for pregnancy.
A patient is in active labor and is experiencing back labor. Which position would be most helpful to relieve the back pain?
- A. Supine position
- B. Hands and knees position
- C. Lithotomy position
- D. Squatting position
Correct Answer: B
Rationale: The correct answer is B: Hands and knees position. This position helps relieve back pain during labor by promoting optimal fetal positioning, reducing pressure on the back, and allowing gravity to assist in the descent of the baby. It also opens up the pelvic outlet, making it easier for the baby to navigate through the birth canal.
Incorrect choices:
A: Supine position can worsen back pain as it puts pressure on the lower back and restricts blood flow to the uterus.
C: Lithotomy position can exacerbate back pain as it involves lying on the back with legs in stirrups, which can increase pressure on the back.
D: Squatting position may not be ideal for relieving back pain in this scenario as it can put additional strain on the back muscles and may not provide optimal support for the laboring individual.
A nurse is assisting with a vaginal delivery. What is the most important nursing intervention when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. perform perineal massage
- C. administer pain relief
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps prevent rapid expulsion of the baby, reducing the risk of perineal tears and minimizing maternal discomfort. It also helps control the delivery process, ensuring a safe and controlled birth.
Incorrect Choices:
B: Perineal massage is not indicated at the crowning stage as it may interfere with the natural birthing process.
C: Administering pain relief should have been addressed earlier in labor and is not a priority at this stage.
D: Administering IV fluids is important for hydration but is not the most critical intervention when the fetal head is crowning.
What does optimal nursing care after an amniocentesis include?
- A. Pushing fluids by mouth
- B. Monitoring uterine activity
- C. Placing the patient in a supine position for 2 hours
- D. Applying a pressure dressing to the puncture site
Correct Answer: B
Rationale: Monitoring uterine activity after an amniocentesis is important to detect any contractions that may indicate complications.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks’ gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: In diabetic pregnancies, an L/S ratio of 2:1 may not reliably indicate lung maturity due to delayed surfactant production.