Nokea
A pregnant patient is at 24 weeks gestation and reports pain in her lower abdomen and back. What is the nurse's first priority action?
- A. Administer pain medication and encourage rest.
- B. Assess the patient for signs of preterm labor, including regular contractions.
- C. Instruct the patient to perform relaxation techniques to alleviate pain.
- D. Encourage the patient to exercise and walk around to relieve discomfort.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdomen and back pain could be indicative of preterm labor. Therefore, the nurse's first priority should be to assess the patient for signs of preterm labor, such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. This is crucial to determine if the patient and the fetus are in any immediate danger. Administering pain medication (choice A), instructing relaxation techniques (choice C), or encouraging exercise (choice D) are not appropriate initial actions as they do not address the potential serious issue of preterm labor.
You may also like to solve these questions
The nurse is caring for a pregnant patient who is 30 weeks gestation and reports feeling faint and lightheaded. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to lie on her back to improve circulation.
- B. Encourage the patient to take deep breaths and sit down immediately.
- C. Instruct the patient to stand up slowly and rest for 10 minutes.
- D. Ask the patient to eat something sweet to raise her blood sugar.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to take deep breaths and sit down immediately. This action is appropriate because the patient is experiencing symptoms of hypotension, which can lead to decreased blood flow to the brain causing faintness and lightheadedness. By encouraging the patient to take deep breaths and sit down immediately, the nurse is helping to increase oxygen intake and improve circulation, which can alleviate the symptoms.
Explanation for why the other choices are incorrect:
A: Instructing the patient to lie on her back can actually worsen symptoms as it can lead to a decrease in blood flow to the brain.
C: Instructing the patient to stand up slowly is not appropriate as the patient is already feeling faint and lightheaded. This can increase the risk of falling and injury.
D: Asking the patient to eat something sweet may not address the underlying cause of the symptoms, which is likely related to hypotension. It is important to address the immediate
A pregnant patient who is 18 weeks gestation reports that she has not felt her baby move for several hours. What should the nurse instruct the patient to do?
- A. Drink a cold beverage and lie down to count fetal movements.
- B. Wait until the morning and report any continued lack of movement to your doctor.
- C. Rest and refrain from worrying, as it is common for fetal movements to decrease.
- D. Call your doctor immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A because decreased fetal movement could indicate a potential problem. Drinking a cold beverage and lying down can stimulate the baby to move, allowing the patient to count fetal movements. This can help assess the baby's well-being. Choice B is incorrect as waiting can delay necessary intervention. Choice C is incorrect as decreased fetal movement should not be dismissed without assessment. Choice D is incorrect as immediate action is needed but calling the doctor alone may not provide immediate relief or guidance.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most important action to promote fetal descent?
- A. coach the person through controlled pushing
- B. increase maternal hydration
- C. provide comfort measures
- D. apply gentle pressure to the abdomen
Correct Answer: A
Rationale: The correct answer is A: coach the person through controlled pushing. This is the most important action to promote fetal descent during the second stage of labor because pushing helps the baby move through the birth canal. Controlled pushing helps prevent exhaustion and reduces the risk of maternal injury. Increasing maternal hydration (choice B) is important for overall well-being but does not directly promote fetal descent. Comfort measures (choice C) are important for pain management but do not directly aid in fetal descent. Applying gentle pressure to the abdomen (choice D) is not recommended as it can interfere with the natural process of labor.
A pregnant patient is asking about the risks of smoking during pregnancy. Which of the following is the most appropriate response by the nurse?
- A. Smoking during pregnancy is safe if you don't have other complications.
- B. Smoking increases the risk of premature birth, low birth weight, and developmental delays.
- C. It's okay to smoke in moderation during pregnancy as long as you quit before delivery.
- D. Smoking only affects the mother, not the baby.
Correct Answer: B
Rationale: The correct answer is B because smoking during pregnancy significantly increases the risk of adverse outcomes such as premature birth, low birth weight, and developmental delays. Nicotine and other harmful chemicals in cigarettes can restrict oxygen and nutrients to the baby, leading to these complications. Choice A is incorrect as smoking is never safe during pregnancy. Choice C is incorrect as any amount of smoking during pregnancy is harmful. Choice D is incorrect as smoking affects both the mother and the baby due to the harmful substances passing through the placenta.
A pregnant patient at 36 weeks gestation is experiencing swelling in her hands and feet. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Instruct the patient to rest and elevate her legs regularly.
- C. Advise the patient to drink more water and reduce sodium intake.
- D. Encourage the patient to take a warm bath to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A. At 36 weeks gestation, swelling in the hands and feet could be a sign of preeclampsia, a serious condition. The nurse's priority is to monitor the patient's blood pressure and assess for other signs of preeclampsia, such as headache, visual disturbances, and proteinuria. Prompt detection and management of preeclampsia are crucial to prevent complications like eclampsia and HELLP syndrome. Choices B, C, and D do not address the potential seriousness of the situation and may delay the necessary assessment and intervention for preeclampsia.