Maternal Monitoring

Maternal Monitoring Related

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A pregnant patient is at 30 weeks gestation and is experiencing dizziness and lightheadedness when standing. What is the nurse's first priority action?

  • A. Encourage the patient to drink fluids and rest for 10 minutes.
  • B. Instruct the patient to lie flat on her back to restore circulation.
  • C. Monitor the patient's blood pressure and check for signs of anemia.
  • D. Administer oxygen and prepare for immediate delivery.
Correct Answer: A

Rationale: The correct answer is A: Encourage the patient to drink fluids and rest for 10 minutes. This is the first priority action because dizziness and lightheadedness in a pregnant patient at 30 weeks gestation could be due to orthostatic hypotension, a common issue in pregnancy. Encouraging the patient to drink fluids and rest will help increase blood volume and alleviate symptoms.

Choice B is incorrect because lying flat on her back can worsen symptoms due to supine hypotensive syndrome. Choice C is not the first priority as checking for anemia or monitoring blood pressure should come after addressing immediate symptoms. Choice D is incorrect because immediate delivery is not warranted based on the symptoms described.

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What complication can result from untreated respiratory distress in the newborn?

  • A. Esophageal atresia
  • B. Gastric dilation
  • C. Cold stress
  • D. Reopening of the foramen ovale
Correct Answer: D

Rationale: Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.

A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?

  • A. apply warm compresses
  • B. apply cold compresses
  • C. provide distraction techniques
  • D. apply lanolin cream
Correct Answer: B

Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.

A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?

  • A. Magnesium sulfate
  • B. Prostaglandin suppository
  • C. RhoGAM if the patient is Rh-negative
  • D. Betamethasone
Correct Answer: C

Rationale: Rh-negative women undergoing CVS require RhoGAM to prevent Rh sensitization.

The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?

  • A. The nurse midwife saw that the mucous plug was intact.
  • B. The nurse midwife felt the baby rebound after being pushed.
  • C. The nurse midwife palpated the fetal parts through the uterine wall.
  • D. The nurse midwife assessed that the baby is head down.
Correct Answer: B

Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.

What fetal change occurs when the fundal height reaches the xiphoid process?

  • A. Surfactant forms in lungs
  • B. Eyes begin to open and close
  • C. Respiratory movements begin
  • D. Spinal column is complete
Correct Answer: A

Rationale: Surfactant production begins in the lungs around this stage of pregnancy, preparing them for postnatal breathing.

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