A pregnant patient is 30 weeks gestation and is concerned about gestational hypertension. Which of the following is a key sign of gestational hypertension?
- A. Severe headache and visual changes
- B. Sudden swelling of the hands and feet
- C. Excessive weight loss and fatigue
- D. Frequent urination and dehydration
Correct Answer: B
Rationale: The correct answer is B: Sudden swelling of the hands and feet. Gestational hypertension is characterized by sudden onset of high blood pressure after 20 weeks of pregnancy, leading to fluid retention and swelling. This is known as preeclampsia, a severe form of gestational hypertension. Swelling in the hands and feet is a key sign due to fluid imbalance. Severe headache and visual changes (choice A) are more indicative of preeclampsia complications. Excessive weight loss and fatigue (choice C) are not typical signs of gestational hypertension. Frequent urination and dehydration (choice D) are not directly related to gestational hypertension.
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The nurse is caring for a pregnant patient at 38 weeks gestation who is experiencing sudden, severe abdominal pain and vaginal bleeding. What should the nurse do first?
- A. Assess the fetal heart rate and prepare for delivery.
- B. Encourage the patient to rest and monitor for changes in symptoms.
- C. Call the healthcare provider immediately to report the symptoms.
- D. Provide pain relief and monitor the patient's vital signs.
Correct Answer: C
Rationale: The correct answer is C: Call the healthcare provider immediately to report the symptoms. This is the first step because sudden, severe abdominal pain and vaginal bleeding in a pregnant patient at 38 weeks gestation could indicate a serious complication such as placental abruption or preterm labor. Notifying the healthcare provider promptly allows for timely intervention and appropriate management.
Choice A is incorrect as assessing the fetal heart rate and preparing for delivery should not be the first action without consulting the healthcare provider. Choice B is incorrect as encouraging the patient to rest is not appropriate in this emergent situation. Choice D is incorrect as providing pain relief and monitoring vital signs should not take precedence over notifying the healthcare provider for further evaluation and management.
A pregnant patient has received the results of her triple-screen testing and it is positive. What would the nurse anticipate as the next step in the patient’s plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: A positive triple-screen test suggests an increased risk of genetic abnormalities, requiring additional diagnostic testing.
A client, in her third trimester, is concerned that she will not know the difference between labor contractions and normal aches and pains of pregnancy.
- A. Don't worry. You'll know the difference when the contractions start.
- B. The contractions may feel just like a backache
- C. but they will come and go.
- D. Contractions are a lot worse than your pregnancy aches and pains.
Correct Answer: B
Rationale: Labor contractions typically have a pattern, coming and going at regular intervals, whereas normal aches and pains do not follow such a predictable pattern.
A pregnant woman who is 24 weeks gestation is experiencing excessive vomiting and dehydration. Which of the following interventions should the nurse prioritize?
- A. Administer an antiemetic to control vomiting.
- B. Encourage the patient to rest and avoid moving too much.
- C. Start intravenous fluids to restore hydration and electrolytes.
- D. Recommend that the patient eat smaller, more frequent meals.
Correct Answer: C
Rationale: The correct answer is C, starting intravenous fluids to restore hydration and electrolytes. This is the priority intervention because dehydration during pregnancy can lead to serious complications for both the mother and the baby. By administering IV fluids, the nurse can quickly rehydrate the mother and replenish electrolytes to ensure the well-being of both.
Choice A (Administer an antiemetic) may help control vomiting, but addressing dehydration is the primary concern. Choice B (Encourage rest) is important, but without addressing hydration first, rest alone will not resolve the issue. Choice D (Recommend smaller meals) may be helpful in managing nausea, but it does not address the immediate need for hydration and electrolyte balance.
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head begins to crown?
- A. apply gentle downward pressure
- B. administer pain relief
- C. administer analgesics
- D. perform perineal massage
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent the baby from being born too quickly, reducing the risk of tearing for the mother. It also ensures a controlled delivery, decreasing the likelihood of complications such as shoulder dystocia. Administering pain relief (B) or analgesics (C) may be necessary but not the most crucial at this moment. Performing perineal massage (D) is beneficial for reducing the risk of tearing but is not as important as guiding the baby's head during crowning.