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A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
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A pregnant patient is at 24 weeks gestation and reports feeling fatigued and weak. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to rest and avoid physical activity.
- B. Assess the patient's hemoglobin and hematocrit levels to check for anemia.
- C. Recommend that the patient eat a high-calorie diet to increase energy.
- D. Encourage the patient to perform regular exercise to combat fatigue.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's hemoglobin and hematocrit levels to check for anemia. Fatigue and weakness in pregnancy can be symptoms of anemia, a common condition due to increased blood volume demands. By checking hemoglobin and hematocrit levels, the nurse can confirm or rule out anemia as the cause. Resting alone may not address the underlying issue, and high-calorie diet or regular exercise may not be appropriate if anemia is present. It is crucial to identify the root cause to provide the most effective intervention.
A client asks the nurse what was meant when the physician told her she had a positive Chadwick’s sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time?
- A. It is a purplish stretch mark on your abdomen.
- B. It means that you are having heart palpitations.
- C. It is a bluish coloration of your cervix and vagina.
- D. It means the doctor heard abnormal sounds when you breathed in.
Correct Answer: C
Rationale: Chadwick’s sign is a bluish coloration of the cervix and vagina due to increased blood flow, which is a common early sign of pregnancy.
A woman in labor who is receiving oxytocin starts to experience uterine hyperstimulation. What should the nurse do first?
- A. Stop the oxytocin infusion
- B. Administer a tocolytic agent
- C. Increase the oxytocin infusion rate
- D. Position the patient on her left side
Correct Answer: A
Rationale: The correct answer is A: Stop the oxytocin infusion. Uterine hyperstimulation can lead to fetal distress and compromise maternal and fetal well-being. Stopping the oxytocin infusion is the first step to prevent further complications. Administering a tocolytic agent (B) is not the initial action for uterine hyperstimulation. Increasing the oxytocin infusion rate (C) would exacerbate the hyperstimulation. Positioning the patient on her left side (D) can help improve blood flow but is not the priority in this situation.
The nurse is caring for a pregnant patient who is 38 weeks gestation and has a history of gestational hypertension. Which of the following symptoms would indicate the need for immediate medical attention?
- A. Mild swelling in the feet and ankles
- B. Headaches and blurred vision
- C. Occasional lower back pain
- D. Fatigue and slight nausea
Correct Answer: B
Rationale: The correct answer is B: Headaches and blurred vision. These symptoms can indicate a serious condition called preeclampsia, which can be life-threatening for both the mother and the baby. Headaches and blurred vision are signs of increased blood pressure and potential organ damage. Immediate medical attention is crucial to monitor and manage preeclampsia.
A: Mild swelling in the feet and ankles is common in pregnancy and not necessarily indicative of a serious issue.
C: Occasional lower back pain is also common in pregnancy and may not require immediate medical attention.
D: Fatigue and slight nausea are common pregnancy symptoms and do not typically indicate a need for immediate medical attention.
A client asks the nurse what was meant when the physician told her she had a positive Chadwick’s sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time?
- A. It is a purplish stretch mark on your abdomen.
- B. It means that you are having heart palpitations.
- C. It is a bluish coloration of your cervix and vagina.
- D. It means the doctor heard abnormal sounds when you breathed in.
Correct Answer: C
Rationale: Chadwick’s sign is a bluish coloration of the cervix and vagina due to increased blood flow, which is a common early sign of pregnancy.