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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.
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A nurse is caring for a laboring person who is experiencing late decelerations in fetal heart rate. What is the priority nursing intervention?
- A. place the person on their left side
- B. apply oxygen via mask
- C. administer pain medication
- D. perform a vaginal examination
Correct Answer: A
Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.
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.
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.
A nurse is preparing a laboring person for an emergency cesarean birth. What is the most important nursing intervention prior to the procedure?
- A. administer a preoperative medication
- B. administer pain relief
- C. administer an epidural block
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: administer a preoperative medication. This is crucial prior to an emergency cesarean birth to ensure the person is adequately prepared for the procedure. Preoperative medications can help reduce anxiety, prevent complications such as aspiration during anesthesia induction, and promote smooth recovery post-surgery. Administering pain relief (B) and epidural block (C) may be important for comfort but are not the priority in this urgent situation. Administering IV fluids (D) is generally important in preparation for surgery, but administering preoperative medication takes precedence in this scenario to ensure the person's safety and well-being during the emergency cesarean birth.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during this stage?
- A. coach the person through controlled pushing
- B. assist with spontaneous pushing
- C. assist with deep breathing
- D. offer non-pharmacological pain relief
Correct Answer: B
Rationale: The correct answer is B because in the second stage of labor, it is appropriate to assist the laboring person with spontaneous pushing to facilitate the descent of the baby through the birth canal. Controlled pushing (choice A) may cause fatigue and unnecessary strain. Deep breathing (choice C) is more suitable for the first stage of labor. Non-pharmacological pain relief (choice D) can be helpful but is not the priority in the second stage when the focus should be on pushing effectively.