External Maternal Monitoring

External Maternal Monitoring Related

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A pregnant patient is at 24 weeks gestation and reports occasional cramping and lower abdominal discomfort. What should the nurse do first?

  • A. Assess for signs of preterm labor and monitor the patient for regular contractions.
  • B. Administer pain medications and encourage the patient to rest.
  • C. Perform a pelvic exam to assess for cervical changes.
  • D. Instruct the patient to increase fluid intake and monitor the symptoms.
Correct Answer: A

Rationale: The correct answer is A: Assess for signs of preterm labor and monitor the patient for regular contractions. This is the most appropriate action as the patient is experiencing cramping and lower abdominal discomfort, which could indicate preterm labor. Step 1: Assessing for signs of preterm labor, such as regular contractions, is crucial to determine the patient's condition. Step 2: Monitoring the patient for regular contractions helps in identifying any patterns and assessing the progression of labor. Other choices are incorrect as B: Administering pain medications without assessing for preterm labor can mask important indicators. C: Performing a pelvic exam may increase the risk of infection and is not the priority. D: Instructing the patient to increase fluid intake may not address the potential risk of preterm labor.

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The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods?

  • A. Tofu, legumes, broccoli.
  • B. Corn, yams, green beans.
  • C. Potatoes, parsnips, turnips.
  • D. Cheese, yogurt, fish.
Correct Answer: A

Rationale: Tofu, legumes, and broccoli provide essential nutrients like protein, iron, and calcium that are often lacking in a vegan diet. Corn, yams, and green beans offer carbohydrates and vitamins but lack sufficient protein sources. Potatoes, parsnips, and turnips are starchy vegetables with limited nutritional variety. Cheese, yogurt, and fish are non-vegan options.

The nurse is educating the pregnant patient with a body mass index (BMI) of 33. The nurse knows that teaching has been effective when the patient states which of the following?

  • A. My child may be at increased risk for birth injury.
  • B. My child may have a decreased risk of developing childhood diabetes.
  • C. I will probably give birth vaginally.
  • D. I have a lower risk of developing gestational hypertension.
Correct Answer: A

Rationale: The correct answer is A: "My child may be at increased risk for birth injury." This is correct because a pregnant patient with a BMI of 33 is considered obese, which can increase the risk of birth injury to the baby due to complications such as macrosomia (large birth weight).

Explanation:
1. Obesity in pregnancy can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
2. Higher BMI can also increase the risk of cesarean delivery, which may be necessary to prevent birth injuries.
3. Childhood diabetes risk is not decreased with maternal obesity.
4. Mode of delivery (vaginal or cesarean) is not solely determined by BMI.
5. Gestational hypertension risk is actually higher in women with obesity.

In summary, choice A is correct because it directly relates to the increased risk of birth injury associated with maternal obesity, while the other choices are not directly linked to the patient's BMI and pregnancy complications.

A 36-week pregnant woman is admitted with ruptured membranes and a positive test for Group B Streptococcus (GBS). What is the appropriate nursing action?

  • A. Start prophylactic antibiotics for the patient
  • B. Perform a cesarean section
  • C. Administer IV fluids
  • D. Provide patient education on labor progression
Correct Answer: A

Rationale: The correct answer is A: Start prophylactic antibiotics for the patient. In this scenario, the woman is at risk for ascending infection due to ruptured membranes and positive GBS test. Prophylactic antibiotics are necessary to prevent neonatal GBS sepsis. Performing a cesarean section is not indicated unless there are other obstetric indications. Administering IV fluids is important but not the priority in this case. Patient education on labor progression is not the immediate concern when the woman is at risk for infection.

Which of the following findings in an 8-week gestation client, G2 P1001, should the nurse highlight for the nurse midwife? Select all that apply.

  • A. Body mass index of 17 kg/m².
  • B. Rubella titer of 1:8.
  • C. Blood pressure of 100/60 mm Hg.
  • D. Hematocrit of 30%.
Correct Answer: A

Rationale: A low BMI, low rubella titer, and low hematocrit are all concerning findings that should be highlighted for further evaluation. A blood pressure of 100/60 mm Hg is within normal limits.

A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits?

  • A. Leg cramps.
  • B. Varicose veins.
  • C. Hemorrhoids.
  • D. Fainting spells.
Correct Answer: A

Rationale: Leg cramps, varicose veins, and hemorrhoids are common complaints during pregnancy due to increased blood volume and pressure on the lower extremities. Fainting spells are not considered normal and may indicate an underlying issue.

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