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A pregnant woman who is 36 weeks gestation reports sudden swelling in her hands and feet, along with a headache. What should the nurse do first?
- A. Instruct the patient to rest and elevate her feet.
- B. Assess the patient's blood pressure and urine for protein.
- C. Encourage the patient to drink plenty of fluids.
- D. Recommend that the patient lie on her left side to improve circulation.
Correct Answer: B
Rationale: The correct answer is B. Assessing the patient's blood pressure and urine for protein is the priority because sudden swelling in hands and feet, along with a headache, could indicate preeclampsia, a serious condition in pregnancy. High blood pressure and protein in the urine are key indicators of preeclampsia. This assessment will help determine if the patient needs immediate medical intervention.
Choice A is incorrect because simply resting and elevating the feet may not address the underlying issue of preeclampsia. Choice C is incorrect as encouraging the patient to drink fluids will not address the potential serious condition. Choice D is incorrect because while lying on the left side can improve circulation, it does not address the urgent need to assess for preeclampsia.
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An 18-week gestation client telephones the obstetrician’s office stating, 'I’m really scared. I think I have breast cancer. My breasts are filled with tumors.' The nurse should base the response on which of the following?
- A. Breast cancer is often triggered by pregnancy.
- B. Nodular breast tissue is normal during pregnancy.
- C. The woman is exhibiting signs of a psychotic break.
- D. Anxiety attacks are especially common in the second trimester.
Correct Answer: B
Rationale: Nodular breast tissue is a normal change during pregnancy due to hormonal fluctuations. Breast cancer is not typically triggered by pregnancy, and anxiety attacks are not specifically common in the second trimester.
The nurse is educating a pregnant patient about the symptoms of preterm labor. Which of the following symptoms should the nurse advise the patient to report immediately?
- A. Occasional low back pain and cramping
- B. Increased vaginal discharge
- C. Painful, regular contractions every 10 minutes or less
- D. Feeling of pelvic pressure after physical activity
Correct Answer: C
Rationale: Step-by-step rationale:
1. Painful, regular contractions every 10 minutes or less can indicate preterm labor.
2. Regular contractions are a sign of the uterus preparing for birth.
3. Painful contractions at regular intervals can progress quickly to preterm delivery.
4. Reporting this symptom immediately allows for timely intervention to prevent premature birth.
Summary:
A: Low back pain and cramping are common in pregnancy but not necessarily indicative of preterm labor.
B: Increased vaginal discharge may be normal in pregnancy and not a direct sign of preterm labor.
C: Painful, regular contractions every 10 minutes or less are a critical sign of preterm labor.
D: Feeling pelvic pressure after physical activity is common in late pregnancy and not specific to preterm labor.
The nurse is caring for a pregnant patient who is complaining of frequent heartburn. Which of the following suggestions would be most helpful for managing heartburn during pregnancy?
- A. Lie down immediately after meals to help with digestion.
- B. Eat smaller meals more frequently throughout the day.
- C. Drink large amounts of water after meals to dilute stomach acid.
- D. Increase intake of spicy foods to stimulate digestion.
Correct Answer: B
Rationale: The correct answer is B: Eat smaller meals more frequently throughout the day. This suggestion helps manage heartburn during pregnancy by preventing large meals that can put pressure on the stomach and lead to acid reflux. Eating smaller, more frequent meals helps maintain stable digestion and minimizes the likelihood of triggering heartburn episodes.
A: Lie down immediately after meals is incorrect because it can worsen heartburn by allowing stomach acid to flow back into the esophagus.
C: Drinking large amounts of water after meals can dilute stomach acid, but it may also distend the stomach and exacerbate heartburn symptoms.
D: Increasing intake of spicy foods can aggravate heartburn due to the potential for irritating the stomach lining and increasing acid production.
A pregnant patient at 28 weeks gestation is experiencing mild back pain. What should the nurse do first?
- A. Administer pain relief and recommend bed rest.
- B. Assess the patient's posture and recommend appropriate exercises.
- C. Encourage the patient to perform light physical activities to strengthen the back muscles.
- D. Instruct the patient to take deep breaths and rest until the pain subsides.
Correct Answer: B
Rationale: The correct answer is B because assessing the patient's posture and recommending appropriate exercises will help address the mild back pain effectively without compromising the safety of the pregnancy. By identifying any postural issues contributing to the pain and recommending suitable exercises, the nurse can promote musculoskeletal health and alleviate discomfort. Administering pain relief without addressing the underlying cause (choice A) may mask symptoms temporarily. Encouraging light physical activities (choice C) could worsen the pain if not tailored to the individual's needs. Instructing the patient to rest and take deep breaths (choice D) may not address the root cause of the back pain.
A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound?
- A. 4 weeks’ gestational age
- B. 6 weeks’ gestational age
- C. 10 weeks’ gestational age
- D. 16 weeks’ gestational age
Correct Answer: C
Rationale: The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound examination.