Nokea
A pregnant patient is at 32 weeks gestation and reports swelling of the feet and legs. What is the most appropriate recommendation for the nurse to make?
- A. Limit fluid intake to reduce swelling.
- B. Elevate the legs and avoid prolonged standing.
- C. Apply compression stockings to improve circulation.
- D. Rest in bed with the feet elevated at all times.
Correct Answer: B
Rationale: The correct answer is B. Elevating the legs and avoiding prolonged standing is the most appropriate recommendation for a pregnant patient experiencing swelling at 32 weeks gestation. Elevating the legs helps to reduce swelling by aiding in venous return and reducing fluid accumulation in the lower extremities. Prolonged standing can worsen swelling due to increased pressure on the veins. Limiting fluid intake (choice A) may lead to dehydration and is not recommended during pregnancy. Applying compression stockings (choice C) may help improve circulation but may not address the underlying cause of swelling. Resting in bed with feet elevated at all times (choice D) is excessive and may not be practical for the patient.
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A pregnant patient at 34 weeks gestation is concerned about the possibility of preterm labor. Which of the following is the most appropriate action for the nurse to take?
- A. Monitor the fetal heart rate and check for signs of labor.
- B. Administer magnesium sulfate to prevent contractions.
- C. Encourage the patient to rest and monitor for changes in symptoms.
- D. Recommend that the patient lie flat on her back for 24 hours.
Correct Answer: A
Rationale: The correct answer is A. Monitoring the fetal heart rate and checking for signs of labor is the most appropriate action as it allows the nurse to assess the status of the pregnancy and the potential onset of preterm labor. This proactive approach helps in early identification and management of any concerning signs or symptoms. Administering magnesium sulfate (choice B) is not appropriate without proper assessment and indication. Encouraging rest and symptom monitoring (choice C) is beneficial but may not be sufficient for evaluating preterm labor. Recommending the patient lie flat on her back for 24 hours (choice D) is not evidence-based and could potentially cause harm.
The nurse is caring for a pregnant patient who is 35 weeks gestation and reports sharp abdominal pain and decreased fetal movement. What is the nurse's priority action?
- A. Encourage the patient to drink water and rest in a comfortable position.
- B. Call the healthcare provider immediately and prepare for further assessment.
- C. Monitor the fetal heart rate and perform a nonstress test.
- D. Ask the patient to lie on her left side and wait for symptoms to resolve.
Correct Answer: B
Rationale: The correct answer is B: Call the healthcare provider immediately and prepare for further assessment. This is the priority action because sharp abdominal pain and decreased fetal movement at 35 weeks gestation could indicate a serious complication such as placental abruption or fetal distress. Calling the healthcare provider promptly allows for timely intervention and assessment to ensure the safety of both the mother and the baby. Encouraging the patient to drink water and rest (choice A) may not address the underlying issue. Monitoring fetal heart rate and performing a nonstress test (choice C) may be important but not as immediate as contacting the healthcare provider. Asking the patient to lie on her left side and wait for symptoms to resolve (choice D) delays necessary medical evaluation and intervention.
A nurse is assisting with a vaginal birth and is monitoring for signs of placental separation. What is the most reliable clinical indicator that the placenta has separated?
- A. a gush of clear amniotic fluid
- B. uterine contractions every 2 to 3 minutes
- C. lengthening of the umbilical cord
- D. maternal report of intense pain
Correct Answer: C
Rationale: The correct answer is C: lengthening of the umbilical cord. This is the most reliable indicator of placental separation because as the placenta detaches from the uterine wall, the cord lengthens as it moves downward. This signifies that the placenta has separated completely.
A: A gush of clear amniotic fluid is not a reliable indicator of placental separation as it can occur before or after placental separation.
B: Uterine contractions every 2 to 3 minutes are a sign of labor progression, not specifically placental separation.
D: Maternal report of intense pain can be subjective and may not always indicate placental separation.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks’ gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: In diabetic pregnancies, an L/S ratio of 2:1 may not reliably indicate lung maturity due to delayed surfactant production.
A nurse is caring for a pregnant patient who is 30 weeks gestation and is diagnosed with mild preeclampsia. Which of the following should be included in the plan of care?
- A. Administer magnesium sulfate to prevent seizures.
- B. Monitor blood pressure and assess for protein in the urine.
- C. Encourage rest and restricted activity to lower blood pressure.
- D. Perform daily blood glucose monitoring for gestational diabetes.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood pressure and assess for protein in the urine. This is crucial in the care of a pregnant patient with mild preeclampsia at 30 weeks gestation. Monitoring blood pressure helps in assessing the severity of the condition and guiding treatment. Assessing for protein in the urine confirms the diagnosis and helps in monitoring kidney function and overall disease progression.
Explanation of why the other choices are incorrect:
A: Administering magnesium sulfate is typically indicated for severe preeclampsia to prevent seizures, not mild preeclampsia.
C: Encouraging rest and restricted activity can help manage symptoms but is not a primary intervention for mild preeclampsia.
D: Daily blood glucose monitoring is important for gestational diabetes, not specifically for mild preeclampsia.