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A pregnant patient at 36 weeks gestation reports feeling more tired than usual. What is the nurse's priority action?
- A. Encourage the patient to get more rest and limit physical activity.
- B. Assess the patient for signs of anemia or other complications.
- C. Administer iron supplements to improve energy levels.
- D. Instruct the patient to increase caloric intake to meet energy demands.
Correct Answer: B
Rationale: The correct answer is B. Assess the patient for signs of anemia or other complications. At 36 weeks gestation, fatigue can be a sign of anemia, a common issue in pregnancy. Anemia can lead to complications for both the mother and the baby, so assessing for this is crucial. Encouraging rest (choice A) may help with fatigue temporarily but does not address the underlying cause. Administering iron supplements (choice C) without assessing first can be harmful if anemia is not the issue. Instructing the patient to increase caloric intake (choice D) is not the priority as it does not address the potential medical issue causing the fatigue.
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The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
- A. Repeat the test in 1 week so that results can be trended based on this baseline result.
- B. Contact the health care provider to discuss birth options for the patient.
- C. Send the patient out for a meal and repeat the test to confirm that the results are valid.
- D. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.
Correct Answer: B
Rationale: A positive CST is an abnormal finding that may indicate fetal compromise, requiring immediate discussion of birth options.
The patient who has received a dose of preservative- free morphine (Duramorph) is beginning to experience pruritus. Which medication is used to treat this?
- A. Low-dose naloxone infusion
- B. Diphenhydramine
- C. Dilaudid
- D. Sublimaze
Correct Answer: B
Rationale: The correct answer is B: Diphenhydramine. Pruritus is a common side effect of opioid medications like morphine. Diphenhydramine, an antihistamine, can help relieve itching. Low-dose naloxone infusion (A) is used for opioid overdose, not pruritus. Dilaudid (C) and Sublimaze (D) are other opioid medications similar to morphine, and using them would not address the pruritus. Diphenhydramine is the most appropriate choice to alleviate the itching without interfering with the pain relief provided by the morphine.
A patient asks the nurse when her infant’s heart will begin to pump blood. What will the nurse reply?
- A. By the end of week 3
- B. Beginning in week 8
- C. At the end of week 16
- D. Beginning in week 24
Correct Answer: A
Rationale: The fetal heart begins to pump by week 3 of gestation.
A pregnant woman informs the nurse that her last normal menstrual period was on September 20, 2012. Using Nagele’s rule, the nurse calculates the client’s estimated date of delivery as:
- A. May 30, 2013.
- B. June 20, 2013.
- C. June 27, 2013.
- D. July 3, 2013.
Correct Answer: C
Rationale: Using Nagele’s rule (adding 7 days to the first day of the last menstrual period, subtracting 3 months, and adding 1 year), the calculated EDD is June 27, 2013.
A nurse is caring for a pregnant patient who is at 22 weeks gestation and reports experiencing vaginal bleeding. What is the nurse's priority action?
- A. Encourage the patient to rest and avoid strenuous activity.
- B. Monitor the fetal heart rate and assess for any signs of preterm labor.
- C. Assess the bleeding and notify the healthcare provider immediately.
- D. Instruct the patient to use a sanitary pad to monitor for changes in bleeding.
Correct Answer: C
Rationale: The correct answer is C: Assess the bleeding and notify the healthcare provider immediately. This is the priority action because vaginal bleeding during pregnancy can indicate serious complications such as placental abruption or preterm labor. By assessing the bleeding, the nurse can determine the severity and nature of the bleeding to provide crucial information to the healthcare provider for prompt intervention. Notifying the healthcare provider immediately ensures timely assessment and appropriate management to protect the health and well-being of both the mother and fetus. Encouraging rest (choice A) may be appropriate, but assessing the bleeding and notifying the healthcare provider take precedence. Monitoring fetal heart rate (choice B) is important but secondary to assessing the bleeding. Instructing the patient to use a sanitary pad (choice D) is not sufficient to address the potential underlying causes of vaginal bleeding.