Nokea
A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of the following comments by the nurse is appropriate at this time?
- A. We expect you to gain about 1 lb per week, so your weight is a little low at this time.
- B. Most women gain no weight during the first trimester, so I would suggest you eat fewer desserts for the next few weeks.
- C. You entered the pregnancy well underweight, so we should check your diet to make sure you are getting the nutrients you need.
- D. Your weight gain is exactly what we would expect it to be at this time.
Correct Answer: D
Rationale: A weight gain of 3 to 5 lb is expected during the first trimester. The client's weight gain is within the normal range.
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In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
- A. every 5 minutes with contractions
- B. at least every 30 minutes
- C. every 5–15 minutes
- D. only when the physician orders assessment
Correct Answer: C
Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.
A client is 15 weeks pregnant. She calls the obstetric office to request a medication for a headache. The nurse answers the telephone. Which of the following is the nurse’s best response?
- A. Because the organ systems in the baby are developing right now, it is risky to take medicine.
- B. You can take any of the over-the-counter medications because they are all safe in pregnancy.
- C. The physician will prescribe a category 'X' medication for you.
- D. You can take acetaminophen because it is a category 'B' medicine.
Correct Answer: D
Rationale: Acetaminophen is a category 'B' medication, which is considered safe during pregnancy. Other over-the-counter medications may not be safe, and category 'X' medications are contraindicated.
A nurse is caring for a pregnant patient who is at 24 weeks gestation and reports difficulty breathing, especially when lying flat. Which action should the nurse take first?
- A. Assess the patient's respiratory rate and oxygen saturation.
- B. Encourage the patient to rest and limit physical activity.
- C. Administer oxygen and prepare the patient for delivery.
- D. Ask the patient to lie on her left side and monitor for improvement.
Correct Answer: A
Rationale: Step 1: Assessing the patient's respiratory rate and oxygen saturation is essential to determine the severity of the breathing difficulty.
Step 2: It helps in identifying potential respiratory issues or complications that may require immediate intervention.
Step 3: This data will guide the nurse in making informed decisions regarding further management and treatment.
Step 4: Encouraging rest (B) may be appropriate after assessment. Administering oxygen and preparing for delivery (C) is premature without assessment. Asking the patient to lie on her left side (D) without initial assessment may delay necessary interventions.
The nurse is providing education to a pregnant patient about diet during pregnancy. Which of the following statements indicates that the patient needs further teaching?
- A. I should increase my intake of fruits, vegetables, and whole grains.
- B. I need to limit my intake of high-fat and high-sugar foods.
- C. I can eat whatever I want as long as I am gaining weight steadily.
- D. I should drink plenty of water and stay hydrated throughout the day.
Correct Answer: C
Rationale: The correct answer is C because the statement "I can eat whatever I want as long as I am gaining weight steadily" indicates a misunderstanding of healthy eating during pregnancy. The rationale is that pregnancy is a crucial time for proper nutrition, and simply focusing on weight gain without considering the quality of food can lead to health risks for both the mother and the baby. Choices A, B, and D are all correct statements that promote a healthy diet during pregnancy by emphasizing the importance of nutrient-dense foods, limiting unhealthy choices, and staying hydrated.
A woman, 26-weeks’ gestation, calls the triage nurse stating, 'I’m really scared. I tried not to but I had an orgasm when we were making love. I just know that I will go into preterm labor now.'
- A. Lie down and drink a quart of water. If you feel any back pressure at all call me back right away.
- B. Although oxytocin was responsible for your orgasm it is very unlikely that it will stimulate preterm labor.
- C. I will inform the doctor for you. What I want you to do is to come to the hospital right now to be checked.
- D. The best thing for you to do right now is to take a warm shower and then do a fetal kick count assessment.
Correct Answer: B
Rationale: Oxytocin released during orgasm does not typically trigger preterm labor. Reassurance is appropriate unless there are other risk factors present.