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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.
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A nurse is caring for a laboring person who is experiencing fetal bradycardia. What is the priority nursing intervention?
- A. administer oxygen
- B. administer IV fluids
- C. increase maternal hydration
- D. increase maternal oxygen
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal bradycardia indicates decreased oxygen supply to the fetus, which can lead to fetal distress. Administering oxygen helps improve oxygen levels in the mother's blood, increasing oxygen delivery to the fetus. This intervention is crucial in preventing further complications and ensuring the well-being of the baby. Administering IV fluids (B) and increasing maternal hydration (C) may be beneficial but do not directly address the immediate need for oxygen. Increasing maternal oxygen (D) is redundant since the primary focus should be on fetal oxygenation.
A pregnant patient is at 30 weeks gestation and reports severe heartburn after eating. What is the nurse's most appropriate intervention?
- A. Instruct the patient to take over-the-counter antacids and lie down to relieve symptoms.
- B. Encourage the patient to eat smaller meals and avoid lying down after eating.
- C. Advise the patient to avoid spicy foods and increase protein intake.
- D. Recommend that the patient take proton pump inhibitors for relief.
Correct Answer: B
Rationale: The correct answer is B because encouraging the patient to eat smaller meals and avoid lying down after eating helps prevent stomach acid from refluxing into the esophagus, reducing heartburn. This intervention addresses the root cause of the symptoms during pregnancy. Option A is incorrect as antacids can provide temporary relief but do not prevent heartburn. Option C is incorrect as spicy foods and protein intake do not directly impact heartburn. Option D is incorrect as proton pump inhibitors are not typically recommended during pregnancy due to potential risks to the fetus.
The nurse is caring for a patient who is in labor and being externally monitored. What should the nurse do after noting early decelerations of the FHR?
- A. Anticipate a cesarean birth
- B. Turn the patient onto the left side
- C. Continue to monitor the patient
- D. Notify the physician or nurse midwife immediately
Correct Answer: C
Rationale: The correct answer is C: Continue to monitor the patient. Early decelerations are benign and occur due to head compression during contractions. They are a normal response to fetal head compression and do not require any intervention as they are self-limiting. Continuing to monitor the patient allows the nurse to observe the pattern of decelerations and ensure they remain early and resolve on their own. Anticipating a cesarean birth (choice A) is unnecessary as early decelerations do not indicate fetal distress. Turning the patient onto the left side (choice B) is typically done for late decelerations, not early decelerations. Notifying the physician or nurse midwife immediately (choice D) is not necessary for early decelerations as they are expected and do not require immediate intervention.
A nurse is assessing a postpartum person for signs of urinary retention. What is the most common sign of urinary retention in the postpartum period?
- A. Abdominal distension
- B. Frequent voiding
- C. No voiding for several hours
- D. Urinary urgency
Correct Answer: C
Rationale: The correct answer is C: No voiding for several hours. Postpartum urinary retention is common due to trauma during childbirth. The bladder may be unable to contract effectively, leading to a lack of sensation to void. This can result in no voiding for several hours. Abdominal distension (A) is not specific to urinary retention. Frequent voiding (B) and urinary urgency (D) are not characteristic signs of urinary retention; they are more indicative of overactive bladder or urinary tract infection.
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.