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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.
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A pregnant patient is at 30 weeks gestation and is experiencing difficulty breathing, especially when lying flat. What is the nurse's priority action?
- A. Encourage the patient to rest in an upright position.
- B. Administer oxygen and prepare the patient for delivery.
- C. Monitor the fetal heart rate for signs of distress.
- D. Instruct the patient to take deep breaths and stay in bed.
Correct Answer: A
Rationale: The correct answer is A - Encourage the patient to rest in an upright position. This is the priority action because the patient is likely experiencing supine hypotensive syndrome due to pressure on the vena cava when lying flat. This can compromise blood flow to the fetus. By having the patient rest in an upright position, the pressure on the vena cava is reduced, improving blood flow and oxygenation for both the patient and the fetus. Administering oxygen and preparing for delivery (option B) is not the immediate priority. Monitoring fetal heart rate (option C) is important but not the initial action. Instructing the patient to take deep breaths and stay in bed (option D) does not address the underlying issue of supine hypotensive syndrome.
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.
A nurse is assessing a postpartum person for signs of thrombophlebitis. What is the most common sign of thrombophlebitis?
- A. redness and swelling in the calf
- B. pain and swelling in the leg
- C. hardening of the calf
- D. heat intolerance in the leg
Correct Answer: B
Rationale: The correct answer is B: pain and swelling in the leg. Thrombophlebitis is inflammation of a vein due to a blood clot, commonly occurring in the lower extremities. Pain and swelling are classic symptoms due to the clot obstructing blood flow. Redness and heat may be present but are not as specific. Hardening of the calf is not a common sign. Heat intolerance in the leg is not a typical symptom of thrombophlebitis.
A pregnant patient is at 28 weeks gestation and reports leg cramps. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to stretch the legs and elevate them to alleviate the cramps.
- B. Recommend that the patient increase calcium intake through dietary changes.
- C. Administer prescribed pain medication to relieve discomfort.
- D. Encourage the patient to walk for 30 minutes each day to prevent cramps.
Correct Answer: A
Rationale: The correct answer is A. Leg cramps during pregnancy are common due to increased weight and pressure on leg muscles. Stretching and elevating legs can help alleviate cramps by improving circulation and reducing muscle tension. Increasing calcium intake (B) may help prevent cramps but is not the immediate action needed. Administering pain medication (C) should be avoided unless absolutely necessary. Walking (D) is beneficial for overall health during pregnancy but may not directly address the immediate leg cramps.
A nurse is caring for a postpartum person who is experiencing difficulty with breastfeeding. What is the most appropriate intervention?
- A. assist with latching
- B. provide skin-to-skin contact
- C. educate the person on breast care
- D. educate the person on postpartum care
Correct Answer: B
Rationale: The correct answer is B: provide skin-to-skin contact. This is the most appropriate intervention because it promotes bonding, regulates the baby's temperature, and enhances breastfeeding success by stimulating the baby's natural instincts. Assisting with latching (choice A) may be necessary but providing skin-to-skin contact should be prioritized. Educating on breast care (choice C) and postpartum care (choice D) are important, but the immediate need is to establish successful breastfeeding through skin-to-skin contact.