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A pregnant patient is 28 weeks gestation and reports feeling nauseated. What is the nurse's priority intervention?
- A. Encourage the patient to drink ginger tea to alleviate nausea.
- B. Recommend the patient eat larger meals to prevent nausea.
- C. Encourage the patient to eat smaller, more frequent meals.
- D. Instruct the patient to avoid all foods and drinks until the nausea resolves.
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to eat smaller, more frequent meals. This is the priority intervention because nausea during pregnancy, especially in the second trimester, is common and can be alleviated by eating smaller, more frequent meals to prevent fluctuations in blood sugar levels. Ginger tea (A) may help with nausea, but ensuring proper nutrition through small, frequent meals is the priority. Recommending larger meals (B) can worsen nausea due to increased stomach distention. Instructing the patient to avoid all foods and drinks (D) is not appropriate as it can lead to dehydration and nutrient deficiencies.
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A nurse is caring for a pregnant patient who is 28 weeks gestation and has been diagnosed with gestational diabetes. What is the nurse's priority teaching for this patient?
- A. Encourage the patient to exercise vigorously to manage blood sugar levels.
- B. Monitor blood glucose levels regularly and follow a balanced diet.
- C. Instruct the patient to limit fluid intake to prevent complications.
- D. Recommend insulin therapy immediately to control blood sugar levels.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose levels regularly and follow a balanced diet. This is the priority teaching for a pregnant patient with gestational diabetes because it focuses on managing blood sugar levels effectively. Regular monitoring helps the patient understand how their body responds to different foods and activities. Following a balanced diet helps maintain stable blood sugar levels and provides essential nutrients for the baby's development.
A: Encouraging vigorous exercise may not be safe during pregnancy, especially for a patient with gestational diabetes.
C: Limiting fluid intake is not a priority teaching for gestational diabetes and may lead to dehydration, which can be harmful during pregnancy.
D: Recommending insulin therapy immediately is not the first-line treatment for gestational diabetes. Lifestyle modifications like diet and exercise are usually tried first.
A nurse is caring for a pregnant patient who is at 26 weeks gestation and reports a sudden decrease in fetal movement. Which action should the nurse take first?
- A. Encourage the patient to drink a sugary beverage and count fetal movements.
- B. Monitor the patient's blood pressure and assess for any signs of hypertension.
- C. Perform a nonstress test to assess fetal well-being.
- D. Call the healthcare provider immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a sugary beverage and count fetal movements. This action is appropriate as decreased fetal movement can indicate fetal distress, and the sugary beverage can stimulate the baby to move. If the baby responds with increased movements, it indicates a reassuring fetal status. If there is no improvement, further evaluation can be pursued.
Incorrect choices:
B: Monitoring blood pressure is not the priority in this situation as the main concern is fetal movement.
C: Performing a nonstress test is not the first action to take as it requires time and resources, which may delay immediate intervention.
D: While eventually contacting the healthcare provider is important, the immediate action should be to assess fetal well-being by encouraging fetal movements.
A client enters the prenatal clinic. She states that she missed her period yesterday and used a home pregnancy test this morning. She states that the results were negative, but 'I still think I am pregnant.' Which of the following statements would be appropriate for the nurse to make at this time?
- A. Your period is probably just irregular.
- B. We could do a blood test to check.
- C. Home pregnancy test results are very accurate.
- D. My recommendation would be to repeat the test in one week.
Correct Answer: B
Rationale: A blood test is more accurate than a home pregnancy test, especially early in pregnancy. Repeating the test in a week is also an option, but a blood test provides more immediate and reliable results.
How often should the nurse assess the blood pressure, pulse, and respirations of the birthing person during the first hour of the fourth stage of labor?
- A. every 15 minutes
- B. every 30 minutes
- C. not until after the first hour
- D. once, then hourly
Correct Answer: A
Rationale: The correct answer is A: every 15 minutes. During the first hour of the fourth stage of labor, immediate postpartum assessment is crucial to monitor for any signs of complications such as hemorrhage or shock. Assessing vital signs every 15 minutes allows for early detection of any abnormalities and prompt intervention. This frequency ensures close monitoring of the birthing person's condition and helps in early identification of any potential issues. Choices B, C, and D are incorrect because less frequent assessments may delay the identification of complications, potentially leading to serious consequences. Option C, in particular, is dangerous as it suggests delaying assessments when immediate postpartum monitoring is essential.
When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent?
- A. Congenital heart defects
- B. Neural tube defects
- C. Mental retardation
- D. Premature birth
Correct Answer: B
Rationale: It is now known that folic acid supplements can prevent neural tube defects such as spina bifida.