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A pregnant patient is at 34 weeks gestation and reports sudden sharp abdominal pain and difficulty breathing. What is the nurse's priority action?
- A. Encourage the patient to lie down and monitor the symptoms.
- B. Administer pain medication and schedule an ultrasound.
- C. Call the healthcare provider immediately and prepare for possible preterm labor.
- D. Assess the fetal heart rate and monitor for contractions.
Correct Answer: C
Rationale: The correct answer is C - Call the healthcare provider immediately and prepare for possible preterm labor. At 34 weeks gestation, sudden sharp abdominal pain and difficulty breathing could indicate a serious complication such as placental abruption or pulmonary embolism. Calling the healthcare provider ensures prompt assessment and appropriate intervention to prevent harm to the mother and baby. Encouraging the patient to lie down may delay necessary intervention. Administering pain medication before determining the cause of pain could mask important symptoms. Assessing the fetal heart rate and monitoring for contractions are important but secondary actions to calling the healthcare provider in this urgent situation.
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A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
- A. ensure the birthing person is positioned correctly
- B. check for allergies to anesthesia
- C. administer a test dose of anesthesia
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
The nurse is assessing a pregnant patient who is at 14 weeks gestation and reports light vaginal bleeding. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and check for protein in the urine.
- B. Call the healthcare provider immediately to assess for miscarriage.
- C. Encourage the patient to rest and wait for symptoms to resolve.
- D. Perform a pelvic exam to check for cervical dilation.
Correct Answer: B
Rationale: The correct answer is B: Call the healthcare provider immediately to assess for miscarriage. The priority action in this scenario is to promptly notify the healthcare provider to assess for potential complications like miscarriage, which could be life-threatening to the patient or fetus. This step ensures timely intervention and appropriate management. Monitoring blood pressure and urine for protein (Choice A) is important but not the immediate priority. Encouraging rest and waiting for symptoms to resolve (Choice C) may delay necessary medical intervention. Performing a pelvic exam (Choice D) could potentially worsen the situation if miscarriage is occurring. Thus, calling the healthcare provider for assessment is the most appropriate and urgent action to take in this situation.
A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
- A. ensure the birthing person is in a sitting position
- B. check for allergies to anesthesia
- C. ensure informed consent is obtained
- D. administer IV fluids
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically.
Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.
A 36-week gestation gravid lies flat on her back.
- A. Hypertension.
- B. Dizziness.
- C. Rales.
- D. Chloasma.
Correct Answer: B
Rationale: Lying flat on the back can compress the inferior vena cava, leading to reduced blood flow and dizziness. Chloasma, rales, and hypertension are unrelated to this position.
During the postpartum period, a nurse is caring for a birthing person who is receiving uterotonic medications. The nurse's assessment reveals a boggy and enlarged uterus. What is the nurse's immediate action?
- A. Document the findings as normal.
- B. Continue to administer the uterotonic medication.
- C. Perform fundal massage to promote uterine firmness.
- D. Administer an analgesic for the birthing person's pain.
Correct Answer: C
Rationale: The correct immediate action is C: Perform fundal massage to promote uterine firmness. Fundal massage helps prevent postpartum hemorrhage by promoting uterine contraction and firmness. A: Documenting the findings as normal is incorrect as a boggy and enlarged uterus is not a normal finding postpartum. B: Continuing to administer uterotonic medication without addressing the boggy uterus can lead to ineffective contraction. D: Administering an analgesic for pain does not address the underlying issue of uterine atony.