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A pregnant patient is at 32 weeks gestation and complains of shortness of breath, swelling of the hands, and increased weight gain. What is the nurse's priority action?
- A. Administer oxygen and prepare the patient for a cesarean section.
- B. Assess the patient's blood pressure and check for protein in the urine.
- C. Encourage the patient to rest and elevate the legs.
- D. Instruct the patient to drink plenty of fluids to reduce swelling.
Correct Answer: B
Rationale: The correct answer is B. At 32 weeks gestation, the patient's symptoms suggest possible preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Assessing blood pressure and checking for proteinuria are crucial for diagnosing and managing preeclampsia. Administering oxygen or preparing for a cesarean section is not the priority without proper assessment. Encouraging rest and elevation of legs may help with swelling, but addressing the potential preeclampsia is more urgent. Instructing the patient to drink fluids is not the priority as it does not address the underlying issue of preeclampsia.
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A nurse is educating a birthing person about the signs and symptoms of postpartum hemorrhage. Which of the following is an early sign of postpartum hemorrhage?
- A. bright red bleeding
- B. increased blood pressure
- C. severe abdominal pain
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: bright red bleeding. This is an early sign of postpartum hemorrhage because it indicates active bleeding from the uterus. Bright red blood suggests fresh bleeding, which is more concerning than darker blood. Increased blood pressure (B) is not typically associated with postpartum hemorrhage. Severe abdominal pain (C) is more indicative of other complications like uterine rupture. Increased heart rate (D) can be a sign of postpartum hemorrhage, but bright red bleeding is a more specific early indicator.
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 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 nurse is educating a pregnant patient at 32 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is recommended for pregnant patients at 32 weeks gestation. This type of activity helps maintain health without putting excessive strain on the body. Strenuous exercises (Choice A) may increase the risk of injury or complications during pregnancy. Avoiding all physical activity (Choice C) can lead to decreased muscle tone and potential complications. High-impact exercises (Choice D) can be too harsh on the joints and bones during pregnancy. Therefore, moderate exercise is the safest and most beneficial option for pregnant patients at this stage.
The nurse is monitoring her patient during labor and is aware that the only way to determine the objective measurement of uterine contractions is through the use of which modality?
- A. Tocodynamometer
- B. Fetal spiral electrode
- C. IUPC
- D. Palpation
Correct Answer: C
Rationale: The correct answer is C: IUPC (Intrauterine Pressure Catheter). This modality is the only direct and objective measurement of uterine contractions as it provides continuous and precise readings of intrauterine pressure. A: Tocodynamometer measures frequency and duration, but not intensity. B: Fetal spiral electrode monitors fetal heart rate, not uterine contractions. D: Palpation is subjective and not as accurate as IUPC for measuring uterine contractions.