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A woman is 36 weeks’ gestation. Which of the following tests will be done during her prenatal visit?
- A. Glucose challenge test.
- B. Amniotic fluid volume assessment.
- C. Vaginal and rectal cultures.
- D. Karyotype analysis.
Correct Answer: C
Rationale: Vaginal and rectal cultures are performed to check for Group B Streptococcus (GBS), which can affect the newborn. Glucose challenge tests are typically done earlier in pregnancy, and karyotype analysis is not routine.
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The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability?
- A. 14 weeks
- B. 20 weeks
- C. 25 weeks
- D. 30 weeks
Correct Answer: B
Rationale: By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of viability).
A nurse is caring for a laboring person who is in the first stage of labor. What is the most important intervention to support the person during this stage?
- A. provide non-pharmacological pain relief
- B. administer pain relief
- C. administer analgesics
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: provide non-pharmacological pain relief. During the first stage of labor, it is crucial to prioritize non-pharmacological pain relief techniques such as breathing exercises, massage, and positioning to help manage the discomfort and promote comfort. This approach aligns with the goal of supporting the person's natural labor process and minimizing interventions that could potentially affect the progress of labor. Administering pain relief (B) or analgesics (C) may not be necessary or advisable at this stage unless specifically requested by the laboring person or deemed appropriate by the healthcare provider. Administering IV fluids (D) is important for hydration but is not the most critical intervention during the first stage of labor.
A nurse is caring for a pregnant patient who is at 22 weeks gestation and reports experiencing vaginal bleeding. What is the nurse's priority action?
- A. Encourage the patient to rest and avoid strenuous activity.
- B. Monitor the fetal heart rate and assess for any signs of preterm labor.
- C. Assess the bleeding and notify the healthcare provider immediately.
- D. Instruct the patient to use a sanitary pad to monitor for changes in bleeding.
Correct Answer: C
Rationale: The correct answer is C: Assess the bleeding and notify the healthcare provider immediately. This is the priority action because vaginal bleeding during pregnancy can indicate serious complications such as placental abruption or preterm labor. By assessing the bleeding, the nurse can determine the severity and nature of the bleeding to provide crucial information to the healthcare provider for prompt intervention. Notifying the healthcare provider immediately ensures timely assessment and appropriate management to protect the health and well-being of both the mother and fetus. Encouraging rest (choice A) may be appropriate, but assessing the bleeding and notifying the healthcare provider take precedence. Monitoring fetal heart rate (choice B) is important but secondary to assessing the bleeding. Instructing the patient to use a sanitary pad (choice D) is not sufficient to address the potential underlying causes of vaginal bleeding.
When assessing the psychological adjustment of an 8-week gravida, which of the following would the nurse expect to see signs of?
- A. Ambivalence.
- B. Depression.
- C. Anxiety.
- D. Ecstasy.
Correct Answer: A
Rationale: Ambivalence is a common psychological response in early pregnancy as the client adjusts to the idea of being pregnant. Depression, anxiety, and ecstasy are less common at this stage.
A pregnant patient at 26 weeks gestation reports pain in the lower abdomen and back. What should the nurse do first?
- A. Encourage the patient to rest and monitor for changes in symptoms.
- B. Perform a pelvic exam to assess for possible cervical dilation.
- C. Administer pain medication to relieve the discomfort.
- D. Assess the patient's blood pressure and check for signs of preeclampsia.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to rest and monitor for changes in symptoms. At 26 weeks gestation, lower abdominal and back pain could indicate preterm labor. The first step is to have the patient rest to reduce uterine activity. Monitoring for changes in symptoms is crucial to assess if the pain is worsening and if there are any signs of preterm labor. Performing a pelvic exam (B) could potentially stimulate contractions and should be avoided unless absolutely necessary. Administering pain medication (C) does not address the underlying cause and could mask symptoms. Assessing blood pressure for signs of preeclampsia (D) is important but not the first priority in this scenario.