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A pregnant woman who is 28 weeks gestation reports that she feels dizzy and faint when she stands up. What should the nurse instruct the patient to do?
- A. Lie down flat on your back immediately.
- B. Stand up quickly to prevent dizziness from worsening.
- C. Drink a large amount of water to alleviate the dizziness.
- D. Get up slowly and avoid standing for long periods.
Correct Answer: D
Rationale: The correct answer is D, instructing the pregnant woman to get up slowly and avoid standing for long periods. This is because during pregnancy, blood pressure can drop when standing up quickly, leading to dizziness and fainting. Getting up slowly allows the body to adjust gradually, preventing a sudden drop in blood pressure. Standing for long periods can worsen these symptoms, so it is important to avoid prolonged standing.
A: Lying down flat on the back immediately can worsen symptoms in this case by reducing blood flow to the brain.
B: Standing up quickly can exacerbate dizziness and fainting by causing a sudden drop in blood pressure.
C: Drinking a large amount of water may not address the underlying issue of postural hypotension and could potentially worsen symptoms by increasing blood volume without addressing the drop in blood pressure.
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What procedure might the nurse perform to determine the presentation of the fetus?
- A. vaginal exam
- B. ultrasound
- C. palpation of contractions
- D. laboring person interview
Correct Answer: B
Rationale: The correct answer is B: ultrasound. Ultrasound is the most accurate and non-invasive method to determine the presentation of the fetus by visualizing the position of the baby in the womb. It allows the nurse to see if the fetus is in a cephalic (head-down) or breech (feet or buttocks down) position. This information is crucial for assessing the progress of labor and planning appropriate interventions.
A: Vaginal exam is not typically used to determine fetal presentation as it does not provide a clear view of the baby's position.
C: Palpation of contractions helps assess the strength and frequency of contractions but does not directly determine fetal presentation.
D: Laboring person interview may provide valuable information about symptoms and history but does not offer direct insight into fetal presentation.
A nurse is providing prenatal education to a patient who is 22 weeks gestation. Which of the following topics should be emphasized at this stage of pregnancy?
- A. Signs and symptoms of preterm labor
- B. Signs of gestational diabetes
- C. Breastfeeding education
- D. Postpartum care
Correct Answer: A
Rationale: The correct answer is A: Signs and symptoms of preterm labor. At 22 weeks gestation, it is crucial to educate the patient about potential signs of preterm labor to help prevent premature birth and ensure the well-being of the baby. Symptoms such as regular contractions, abdominal cramping, backache, and vaginal bleeding should be discussed. This topic is time-sensitive and requires immediate action if observed.
Summary of other choices:
B: Signs of gestational diabetes - While important, monitoring for gestational diabetes typically occurs later in pregnancy, usually around 24-28 weeks.
C: Breastfeeding education - Important, but not as time-sensitive as preterm labor education.
D: Postpartum care - Relevant but more appropriate for later stages of pregnancy or after birth, not specifically at 22 weeks gestation.
What is the primary purpose of performing an episiotomy during delivery?
- A. to reduce the risk of perineal trauma
- B. to promote faster delivery
- C. to facilitate fetal descent
- D. to provide immediate fetal oxygenation
Correct Answer: A
Rationale: The primary purpose of performing an episiotomy during delivery is to reduce the risk of perineal trauma. Episiotomy is a surgical incision made in the perineum to widen the vaginal opening during childbirth, which can help prevent severe tearing of the perineal tissue. This procedure is performed to provide controlled and precise incision, reducing the likelihood of extensive tears that may lead to complications such as infection or prolonged healing time. It is not done to promote faster delivery, facilitate fetal descent, or provide immediate fetal oxygenation. These choices do not accurately reflect the main goal of episiotomy, which is to minimize perineal trauma.
The nurse plans to provide anticipatory guidance to a 10-week gravid client who is being seen in the prenatal clinic. Which of the following information should be a priority for the nurse to provide?
- A. Pain management during labor.
- B. Methods to relieve backaches.
- C. Breastfeeding positions.
- D. Characteristics of the newborn.
Correct Answer: B
Rationale: Backaches are a common complaint during pregnancy, and providing guidance on how to relieve them is a priority at this stage. Pain management during labor, breastfeeding positions, and newborn characteristics are typically addressed later in pregnancy.
A patient at 37 weeks gestation is admitted with ruptured membranes. What is the first priority action for the nurse?
- A. Assess for signs of infection
- B. Check for cord prolapse
- C. Perform a vaginal exam to assess cervical dilation
- D. Perform a vaginal examination to check for fetal descent
Correct Answer: B
Rationale: The correct answer is B: Check for cord prolapse. This is the first priority action because a prolapsed cord is a life-threatening emergency that requires immediate intervention to prevent fetal hypoxia and distress. The nurse should quickly assess for cord presentation by performing a vaginal exam and relieving pressure on the cord if present.
Incorrect choices:
A: Assess for signs of infection - While infection is a concern with ruptured membranes, it is not the immediate priority over checking for cord prolapse.
C: Perform a vaginal exam to assess cervical dilation - Assessing cervical dilation can wait until after ruling out cord prolapse.
D: Perform a vaginal examination to check for fetal descent - Fetal descent assessment is not urgent compared to checking for cord prolapse in this scenario.