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A pregnant patient is 36 weeks gestation and reports increased vaginal discharge. What is the nurse's priority action?
- A. Assess the nature of the discharge for signs of infection.
- B. Instruct the patient to monitor the discharge at home.
- C. Recommend the patient use panty liners to manage the discharge.
- D. Provide education about normal pregnancy changes, including discharge.
Correct Answer: A
Rationale: The correct answer is A: Assess the nature of the discharge for signs of infection. At 36 weeks gestation, increased vaginal discharge could be a sign of infection, such as bacterial vaginosis or yeast infection, which can lead to preterm labor. The nurse's priority is to assess for infection to prevent any potential harm to the mother and baby. By assessing the nature of the discharge, the nurse can determine if further evaluation or treatment is needed.
Choice B is incorrect because instructing the patient to monitor the discharge at home does not address the potential seriousness of the situation. Choice C is incorrect as using panty liners only manages the symptom without addressing the underlying cause. Choice D is incorrect because providing education about normal pregnancy changes does not address the immediate need to rule out infection in this scenario.
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A nurse is caring for a pregnant patient at 32 weeks gestation who is diagnosed with anemia. What is the nurse's priority teaching for this patient?
- A. You should take iron supplements with milk to improve absorption.
- B. You should take iron supplements with a vitamin C source, such as orange juice.
- C. You should avoid taking iron supplements during the second trimester.
- D. You should take iron supplements with calcium-rich foods to increase absorption.
Correct Answer: B
Rationale: The correct answer is B because vitamin C enhances iron absorption. Iron supplements should be taken with a vitamin C source, such as orange juice, to maximize absorption and effectiveness in treating anemia. Iron absorption is hindered by calcium-rich foods and milk, so options A and D are incorrect. Option C is also incorrect as iron supplementation is crucial during pregnancy to prevent and treat anemia.
A pregnant patient at 28 weeks gestation reports feeling nauseated and vomiting after meals. What is the most appropriate action for the nurse to take?
- A. Encourage the patient to eat large meals less frequently.
- B. Recommend the patient eat smaller, more frequent meals and avoid greasy foods.
- C. Instruct the patient to rest after meals to reduce nausea.
- D. Advise the patient to avoid all foods until the nausea resolves.
Correct Answer: B
Rationale: The correct answer is B: Recommend the patient eat smaller, more frequent meals and avoid greasy foods. This is because smaller, more frequent meals can help alleviate nausea and vomiting during pregnancy by preventing the stomach from becoming too full. Greasy foods can exacerbate nausea, so avoiding them is beneficial.
A: Encouraging large meals less frequently can worsen symptoms by overwhelming the digestive system.
C: Resting after meals may not directly address the underlying cause of nausea and vomiting.
D: Avoiding all foods can lead to inadequate nutrition for both the patient and the developing fetus.
In summary, choice B is the most appropriate as it addresses the symptoms effectively and promotes better nutrition during pregnancy.
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.
What is the most common cause of shoulder dystocia during delivery?
- A. fetal macrosomia
- B. maternal obesity
- C. maternal diabetes
- D. advanced maternal age
Correct Answer: A
Rationale: The correct answer is A: fetal macrosomia. Fetal macrosomia, defined as a birth weight above 4 kg, is the most common cause of shoulder dystocia during delivery. This occurs when the baby's shoulders get stuck behind the mother's pelvic bone, leading to complications. Macrosomia is more likely in pregnancies with gestational diabetes, maternal obesity, and advanced maternal age, but the primary risk factor for shoulder dystocia is fetal macrosomia due to the large size of the baby. Maternal obesity, diabetes, and advanced age are secondary risk factors that can contribute to the likelihood of shoulder dystocia but are not the primary cause.
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.