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A pregnant patient is at 32 weeks gestation and reports a sudden headache and visual disturbances. What is the nurse's priority action?
- A. Encourage the patient to lie down and rest for a while.
- B. Assess the patient's blood pressure and check for protein in the urine.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to drink a caffeinated beverage to relieve symptoms.
Correct Answer: B
Rationale: The correct answer is B because sudden headache and visual disturbances in a pregnant patient at 32 weeks gestation could indicate preeclampsia. Assessing blood pressure and checking for protein in the urine are crucial steps in diagnosing preeclampsia, a serious condition that requires immediate medical attention to prevent complications for both the mother and baby. Encouraging rest, administering pain medication, or suggesting caffeinated beverages may mask symptoms but not address the underlying issue of preeclampsia. Therefore, prompt assessment and monitoring of blood pressure and urine protein levels are essential in this scenario.
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A 40-year-old primiparous woman who is 38 weeks pregnant has been on the labor unit for an hour when she starts to complain of feeling dizzy, light-headed, and nauseous. Her blood pressure is 90/60. What should be the first response of the nurse?
- A. Give the patient a bolus of intravenous fluid.
- B. Turn the patient to her left side.
- C. Call the obstetrician or nurse midwife.
- D. Give the patient an antiemetic medication for the nausea.
Correct Answer: B
Rationale: The correct answer is B: Turn the patient to her left side.
Rationale:
1. The patient's symptoms of dizziness, light-headedness, and low blood pressure (90/60) suggest hypotension, which could be due to supine hypotensive syndrome in pregnancy.
2. Turning the patient to her left side can help alleviate pressure on the vena cava, improving blood flow back to the heart and subsequently increasing blood pressure.
3. This immediate action can help prevent further complications such as decreased placental perfusion and fetal distress.
Summary:
- Choice A (Give the patient a bolus of intravenous fluid): While IV fluids may be needed, the priority is to address the underlying cause of hypotension first.
- Choice C (Call the obstetrician or nurse midwife): While it is important to involve the healthcare provider, immediate action to address the hypotension is crucial.
- Choice D (Give the patient an antiemetic medication for
The nurse is providing education to a pregnant patient who is experiencing nausea and vomiting during pregnancy. Which of the following interventions should the nurse recommend?
- A. Increase fluid intake with large amounts of water at once.
- B. Eat small, frequent meals and avoid greasy foods.
- C. Take over-the-counter anti-nausea medications without consulting a doctor.
- D. Lie flat on your back immediately after eating to prevent reflux.
Correct Answer: B
Rationale: The correct answer is B because eating small, frequent meals and avoiding greasy foods can help manage nausea and vomiting during pregnancy by preventing the stomach from becoming too full or empty. Large amounts of water at once (choice A) can worsen nausea. Taking anti-nausea medications without consulting a doctor (choice C) can be unsafe during pregnancy. Lying flat on your back after eating (choice D) can increase the risk of acid reflux.
A pregnant person in the first stage of labor experiences rupture of membranes. What is the nurse's priority action?
- A. Administer an epidural for pain relief.
- B. Start an IV line and administer antibiotics.
- C. Document the FHR and time and characteristics of the amniotic fluid.
- D. Prepare for immediate delivery.
Correct Answer: C
Rationale: The correct answer is C because documenting the fetal heart rate (FHR) and characteristics of amniotic fluid is crucial to assess fetal well-being and monitor for signs of distress. This information helps guide further management decisions. Administering an epidural (A) is not the priority at this stage. Starting an IV line and administering antibiotics (B) may be needed later but not the immediate priority. Preparing for immediate delivery (D) is premature without assessing the fetal status first.
The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history?
- A. Maternal diabetes
- B. Weight gain of 25 lb
- C. Maternal age older than 30 years
- D. Previous infant weighing more than 3000 g at birth
Correct Answer: A
Rationale: Maternal diabetes is a risk factor in pregnancy due to possible impairment of placental perfusion, necessitating fetal diagnostic procedures.
Place these developmental milestones in chronological order: Four-chambered heart forms, Vernix caseosa appears, Blastocyst development completes, Testes descend
- A. Blastocyst development complete
- B. Four-chambered heart forms
- C. Vernix caseosa present
- D. Testes descend into scrotum
Correct Answer: B
Rationale: Development follows the sequence: blastocyst formation, four-chambered heart, vernix appearance, and testicular descent.