Nokea
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.
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A pregnant patient is concerned about the safety of using over-the-counter medications for her cold symptoms. Which of the following responses is most appropriate for the nurse?
- A. It is always safe to use OTC medications during pregnancy.
- B. You should avoid using any medications during pregnancy unless prescribed by your healthcare provider.
- C. OTC medications for cold symptoms are safe during any trimester of pregnancy.
- D. Use herbal remedies instead of OTC medications to avoid harm to the baby.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. During pregnancy, it is crucial to minimize medication use to prevent potential harm to the fetus.
2. Many OTC medications have not been extensively studied for safety in pregnancy.
3. Healthcare providers can recommend safe and effective treatment options tailored to the individual.
4. Avoiding unnecessary medication reduces the risk of adverse effects on the developing baby.
Summary:
A: Incorrect. Not all OTC medications are safe during pregnancy, and blanket statements can be harmful.
C: Incorrect. Safety of OTC medications can vary by trimester, so blanket statements are not appropriate.
D: Incorrect. Herbal remedies can also pose risks during pregnancy, and individualized guidance is necessary.
A nurse is preparing a laboring person for a cesarean birth. What is the priority action before the procedure?
- A. ensure informed consent is signed
- B. administer preoperative medication
- C. administer IV fluids
- D. administer a sedative
Correct Answer: C
Rationale: The correct answer is C: administer IV fluids. Before a cesarean birth, IV fluids are crucial to maintain hydration and prevent hypotension due to anesthesia. Administering IV fluids helps stabilize the person's blood pressure during the procedure, reducing the risk of complications. A is incorrect because informed consent should be obtained earlier in the process. B is incorrect as preoperative medication is typically given closer to the procedure start time. D is incorrect as administering a sedative may affect the person's ability to participate in decision-making and care during the procedure. Administering IV fluids is the priority to ensure the person's safety and well-being during the cesarean birth.
A 36-week pregnant woman is admitted with ruptured membranes and a positive test for Group B Streptococcus (GBS). What is the appropriate nursing action?
- A. Start prophylactic antibiotics for the patient
- B. Perform a cesarean section
- C. Administer IV fluids
- D. Provide patient education on labor progression
Correct Answer: A
Rationale: The correct answer is A: Start prophylactic antibiotics for the patient. In this scenario, the woman is at risk for ascending infection due to ruptured membranes and positive GBS test. Prophylactic antibiotics are necessary to prevent neonatal GBS sepsis. Performing a cesarean section is not indicated unless there are other obstetric indications. Administering IV fluids is important but not the priority in this case. Patient education on labor progression is not the immediate concern when the woman is at risk for infection.
A woman in labor begins to experience a sudden increase in vaginal bleeding and the fetal heart rate decelerates. What is the likely cause of these symptoms?
- A. Placenta previa
- B. Placental abruption
- C. Uterine rupture
- D. Cervical laceration
Correct Answer: B
Rationale: The correct answer is B: Placental abruption. Placental abruption is the premature separation of the placenta from the uterine wall, leading to vaginal bleeding and fetal distress. The sudden increase in bleeding and fetal heart rate deceleration are hallmark signs of placental abruption. Placenta previa (choice A) involves bleeding without fetal distress. Uterine rupture (choice C) typically presents with severe abdominal pain and shock. Cervical laceration (choice D) would not cause fetal heart rate deceleration.
In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
- A. every 5 minutes with contractions
- B. at least every 30 minutes
- C. every 5–15 minutes
- D. only when the physician orders assessment
Correct Answer: C
Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.