Nokea
A pregnant patient who is 28 weeks gestation reports a sudden headache and visual changes. What is the nurse's priority action?
- A. Encourage the patient to take a warm bath to relieve the headache.
- B. Assess the patient's blood pressure and check for signs of preeclampsia.
- C. Administer pain medication to relieve the headache.
- D. Instruct the patient to rest in a dark, quiet room to relieve symptoms.
Correct Answer: B
Rationale: The correct answer is B. Assess the patient's blood pressure and check for signs of preeclampsia. This is the priority action because sudden headache and visual changes in a pregnant patient at 28 weeks gestation could indicate preeclampsia, a serious condition characterized by high blood pressure and organ damage. Checking blood pressure and signs of preeclampsia is crucial for early detection and prompt management to prevent complications for both the mother and baby. Encouraging a warm bath, administering pain medication, or instructing the patient to rest may provide temporary relief but do not address the underlying cause of the symptoms.
You may also like to solve these questions
What is the first step the nurse should take when assessing a newborn's respiratory status immediately after birth?
- A. observe for respiratory effort
- B. take the newborn's temperature
- C. assist with suctioning the airways
- D. suction the newborn's mouth
Correct Answer: A
Rationale: The correct answer is A: observe for respiratory effort. This is the first step because it helps the nurse quickly assess if the newborn is breathing effectively. Observing for respiratory effort allows for prompt identification of any potential respiratory distress or abnormalities. Taking the newborn's temperature (B) is important but not the first step in assessing respiratory status. Assisting with suctioning the airways (C) should only be done if there are signs of airway obstruction, not as the initial step. Suctioning the newborn's mouth (D) is not recommended immediately after birth unless there is clear obstruction, as this can stimulate unnecessary reflexes and cause harm.
The blood of a pregnant client was initially assessed at 10 weeks’ gestation and reassessed at 38 weeks’ gestation.
- A. Rise in hematocrit from 34% to 38%.
- B. Rise in white blood cells from 5 000 cells/mm3 to 15 000 cells/mm3.
- C. Rise in potassium from 3.9 mEq/L to 5.2 mEq/L.
- D. Rise in sodium from 137 mEq/L to 150 mEq/L.
Correct Answer: B
Rationale: White blood cell count increases during pregnancy due to physiological stress and immune system changes. Hematocrit levels typically decrease due to plasma expansion, while potassium and sodium levels remain stable.
The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix?
- A. They are destroyed by the acidic pH of the vagina.
- B. They survive up to 5 days and can cause pregnancy.
- C. They lose their motility in about 12 hours after intercourse.
- D. They are usually pushed out of the vagina by the muscular action of the vaginal wall.
Correct Answer: B
Rationale: Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.
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.
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.