Nokea
A pregnant patient at 36 weeks gestation is experiencing swelling in her hands and feet. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Instruct the patient to rest and elevate her legs regularly.
- C. Advise the patient to drink more water and reduce sodium intake.
- D. Encourage the patient to take a warm bath to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A. At 36 weeks gestation, swelling in the hands and feet could be a sign of preeclampsia, a serious condition. The nurse's priority is to monitor the patient's blood pressure and assess for other signs of preeclampsia, such as headache, visual disturbances, and proteinuria. Prompt detection and management of preeclampsia are crucial to prevent complications like eclampsia and HELLP syndrome. Choices B, C, and D do not address the potential seriousness of the situation and may delay the necessary assessment and intervention for preeclampsia.
You may also like to solve these questions
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.
A pregnant patient is asking about the risks of smoking during pregnancy. Which of the following is the most appropriate response by the nurse?
- A. Smoking during pregnancy is safe if you don't have other complications.
- B. Smoking increases the risk of premature birth, low birth weight, and developmental delays.
- C. It's okay to smoke in moderation during pregnancy as long as you quit before delivery.
- D. Smoking only affects the mother, not the baby.
Correct Answer: B
Rationale: The correct answer is B because smoking during pregnancy significantly increases the risk of adverse outcomes such as premature birth, low birth weight, and developmental delays. Nicotine and other harmful chemicals in cigarettes can restrict oxygen and nutrients to the baby, leading to these complications. Choice A is incorrect as smoking is never safe during pregnancy. Choice C is incorrect as any amount of smoking during pregnancy is harmful. Choice D is incorrect as smoking affects both the mother and the baby due to the harmful substances passing through the placenta.
What is the priority nursing action when a postpartum person experiences a boggy uterus after delivery?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. administer an analgesic
- D. administer pain medication
Correct Answer: B
Rationale: The correct answer is B: administer a uterotonic medication. This is the priority nursing action because a boggy uterus indicates uterine atony, which can lead to postpartum hemorrhage. Uterotonic medications help the uterus contract and reduce bleeding. Performing fundal massage (A) can be done after administering the medication to aid in uterine contraction. Administering an analgesic (C) or pain medication (D) is not the priority as the main concern is preventing excessive bleeding.
A pregnant patient is 26 weeks gestation and reports difficulty breathing when lying flat. What should the nurse recommend?
- A. Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm.
- B. Recommend sleeping in a fully reclined position to prevent shortness of breath.
- C. Administer oxygen as prescribed to ensure proper oxygenation.
- D. Instruct the patient to lie flat on her back and use a pillow for support.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm. At 26 weeks gestation, the uterus can compress the inferior vena cava when lying flat on the back, leading to decreased blood return to the heart and reduced cardiac output, causing difficulty breathing. Sleeping on the left side helps improve circulation by reducing pressure on the vena cava, enhancing blood flow and oxygenation to the fetus and mother.
Incorrect options:
B: Recommending sleeping in a fully reclined position may not alleviate the compression on the vena cava and could potentially worsen the patient's symptoms.
C: Administering oxygen may help with oxygenation but does not address the underlying issue of vena cava compression due to the growing uterus.
D: Instructing the patient to lie flat on her back can exacerbate the issue by further compressing the vena cava, worsening breathing difficulties.
A pregnant patient with a BMI of 35 is concerned about health effects she and her baby may face during pregnancy. During routine testing, the patient tested negative for sexually transmitted illnesses (STIs) and indicated that she is in a committed, long-term relationship with the child's father. Which of the following is accurate?
- A. The patient's infant is at increased risk of neonatal blindness.
- B. The patient's infant has a decreased risk of birth injury.
- C. The patient will have increased risk of wound infection.
- D. The patient will have a decreased risk of preeclampsia.
Correct Answer: C
Rationale: Rationale:
1. Pregnancy with a high BMI increases the risk of wound infection post-delivery due to delayed wound healing and increased tissue trauma.
2. Negative STI test and committed relationship decrease risks of neonatal blindness and birth injury.
3. Wound infection risk is directly related to BMI and not affected by STI status or relationship status.
Summary:
A: Incorrect - No connection between STI status or relationship status with neonatal blindness.
B: Incorrect - No direct relation between STI status or relationship status with birth injury risk.
D: Incorrect - Preeclampsia risk is not influenced by STI status or relationship status.