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A pregnant woman who is 24 weeks gestation is experiencing excessive vomiting and dehydration. Which of the following interventions should the nurse prioritize?
- A. Administer an antiemetic to control vomiting.
- B. Encourage the patient to rest and avoid moving too much.
- C. Start intravenous fluids to restore hydration and electrolytes.
- D. Recommend that the patient eat smaller, more frequent meals.
Correct Answer: C
Rationale: The correct answer is C, starting intravenous fluids to restore hydration and electrolytes. This is the priority intervention because dehydration during pregnancy can lead to serious complications for both the mother and the baby. By administering IV fluids, the nurse can quickly rehydrate the mother and replenish electrolytes to ensure the well-being of both.
Choice A (Administer an antiemetic) may help control vomiting, but addressing dehydration is the primary concern. Choice B (Encourage rest) is important, but without addressing hydration first, rest alone will not resolve the issue. Choice D (Recommend smaller meals) may be helpful in managing nausea, but it does not address the immediate need for hydration and electrolyte balance.
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A nurse is caring for a laboring person who is experiencing strong contractions. What is the most important intervention to support the laboring person during this time?
- A. provide comfort measures
- B. assist with breathing exercises
- C. provide reassurance and comfort
- D. administer antibiotics
Correct Answer: A
Rationale: The correct answer is A: provide comfort measures. Comfort measures such as massage, positioning, and relaxation techniques help the laboring person cope with the pain and intensity of contractions. By providing comfort, the nurse can help reduce stress and anxiety, promoting a more positive labor experience.
Choice B (assist with breathing exercises) can be helpful, but comfort measures are more essential for overall well-being during labor. Choice C (provide reassurance and comfort) is similar to the correct answer but lacks the specific action of providing comfort measures. Choice D (administer antibiotics) is irrelevant to the management of strong contractions and is not indicated unless there is a specific medical reason for antibiotics.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and is experiencing a sudden increase in vaginal discharge. What is the nurse's priority action?
- A. Check for signs of labor and assess fetal heart rate.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Perform a pelvic exam to assess the amount of discharge.
- D. Call the healthcare provider immediately to report the change in discharge.
Correct Answer: A
Rationale: The correct answer is A because the sudden increase in vaginal discharge at 40 weeks gestation could indicate the onset of labor. Checking for signs of labor, such as contractions and assessing fetal heart rate, is crucial to determine if the patient is in active labor. This helps in timely intervention and ensuring the well-being of both the mother and baby.
Summary:
- Choice B: Encouraging rest and monitoring changes in discharge may not address the urgency of the situation.
- Choice C: Performing a pelvic exam without assessing signs of labor or fetal well-being may delay necessary actions.
- Choice D: While reporting to the healthcare provider is important, immediate assessment of labor signs and fetal heart rate takes precedence.
The nurse is caring for a pregnant patient at 38 weeks gestation who is experiencing sudden, severe abdominal pain and vaginal bleeding. What should the nurse do first?
- A. Assess the fetal heart rate and prepare for delivery.
- B. Encourage the patient to rest and monitor for changes in symptoms.
- C. Call the healthcare provider immediately to report the symptoms.
- D. Provide pain relief and monitor the patient's vital signs.
Correct Answer: C
Rationale: The correct answer is C: Call the healthcare provider immediately to report the symptoms. This is the first step because sudden, severe abdominal pain and vaginal bleeding in a pregnant patient at 38 weeks gestation could indicate a serious complication such as placental abruption or preterm labor. Notifying the healthcare provider promptly allows for timely intervention and appropriate management.
Choice A is incorrect as assessing the fetal heart rate and preparing for delivery should not be the first action without consulting the healthcare provider. Choice B is incorrect as encouraging the patient to rest is not appropriate in this emergent situation. Choice D is incorrect as providing pain relief and monitoring vital signs should not take precedence over notifying the healthcare provider for further evaluation and management.
A nurse is caring for a pregnant patient who is at 32 weeks gestation and reports frequent headaches and nausea. What should the nurse do first?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Administer anti-nausea medication and provide comfort measures.
- C. Encourage the patient to rest and drink fluids.
- D. Schedule a follow-up appointment for further evaluation.
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 32 weeks gestation, headaches and nausea could be symptoms of preeclampsia, a serious condition in pregnancy. Monitoring blood pressure is crucial as preeclampsia is characterized by high blood pressure. Assessing for signs of preeclampsia, such as proteinuria or visual disturbances, is essential for timely intervention. Administering anti-nausea medication or encouraging rest without addressing the possibility of preeclampsia could delay necessary treatment. Scheduling a follow-up appointment without immediate assessment could also put the patient at risk if preeclampsia is present.
A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse’s most appropriate response?
- A. The test results are within normal limits.
- B. Immediate birth by cesarean birth is being considered.
- C. Further testing will be performed to determine the meaning of this score.
- D. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.
Correct Answer: A
Rationale: A score of 8-10 is within the normal range for a biophysical profile, indicating no immediate concerns for the fetus.