Nokea
A pregnant patient who is 18 weeks gestation reports that she has not felt her baby move for several hours. What should the nurse instruct the patient to do?
- A. Drink a cold beverage and lie down to count fetal movements.
- B. Wait until the morning and report any continued lack of movement to your doctor.
- C. Rest and refrain from worrying, as it is common for fetal movements to decrease.
- D. Call your doctor immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A because decreased fetal movement could indicate a potential problem. Drinking a cold beverage and lying down can stimulate the baby to move, allowing the patient to count fetal movements. This can help assess the baby's well-being. Choice B is incorrect as waiting can delay necessary intervention. Choice C is incorrect as decreased fetal movement should not be dismissed without assessment. Choice D is incorrect as immediate action is needed but calling the doctor alone may not provide immediate relief or guidance.
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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 32 weeks gestation reports increased pressure in the pelvic area and mild cramping. What should the nurse assess first?
- A. The fetal heart rate and signs of labor.
- B. The patient's blood pressure and urine for protein.
- C. The presence of vaginal discharge or bleeding.
- D. The patient's dietary intake and hydration status.
Correct Answer: A
Rationale: The correct answer is A: The fetal heart rate and signs of labor. At 32 weeks gestation, any pelvic pressure and cramping could be indicative of preterm labor, which is a critical concern. Assessing the fetal heart rate can help determine fetal well-being and signs of distress. Monitoring for signs of labor such as contractions, cervical changes, and rupture of membranes is essential for timely intervention.
Choice B: Assessing blood pressure and urine for protein is important in monitoring for preeclampsia, but it is not the priority in this case where signs of preterm labor are reported.
Choice C: Vaginal discharge or bleeding could indicate various conditions, but in this scenario, the focus should be on ruling out preterm labor first.
Choice D: Dietary intake and hydration status are important aspects of prenatal care, but they are not the priority when assessing a pregnant patient reporting pelvic pressure and cramping at 32 weeks gestation.
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.
A pregnant patient with a BMI of 35 is concerned about health effects she and her baby may face during pregnancy. During routine testing, the patient tested negative for sexually transmitted illnesses (STIs) and indicated that she is in a committed, long-term relationship with the child's father. Which of the following is accurate?
- A. The patient's infant is at increased risk of neonatal blindness.
- B. The patient's infant has a decreased risk of birth injury.
- C. The patient will have increased risk of wound infection.
- D. The patient will have a decreased risk of preeclampsia.
Correct Answer: C
Rationale: Rationale:
1. Pregnancy with a high BMI increases the risk of wound infection post-delivery due to delayed wound healing and increased tissue trauma.
2. Negative STI test and committed relationship decrease risks of neonatal blindness and birth injury.
3. Wound infection risk is directly related to BMI and not affected by STI status or relationship status.
Summary:
A: Incorrect - No connection between STI status or relationship status with neonatal blindness.
B: Incorrect - No direct relation between STI status or relationship status with birth injury risk.
D: Incorrect - Preeclampsia risk is not influenced by STI status or relationship status.
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.