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In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
- A. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results.
- B. Maintain NPO status prior to testing.
- C. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
- D. Have an infusion pump prepared with oxytocin per protocol for evaluation.
Correct Answer: C
Rationale: The patient should be positioned comfortably, and the tocotransducer should be adjusted to obtain an accurate fetal heart rate reading.
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During a preconception counseling session, the nurse encourages a couple to prepare a birth plan.
- A. Promote communication between the couple and health care professionals.
- B. Enable the couple to learn about the types of pain medicine used in labor.
- C. Provide the couple with a list of items that they should take to the hospital for the labor and delivery.
- D. Give the high-risk couple a sense of control over the likelihood of having a surgical delivery.
Correct Answer: A
Rationale: A birth plan fosters open communication between the couple and healthcare providers, ensuring that expectations and preferences are understood.
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
- A. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results.
- B. Maintain NPO status prior to testing.
- C. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
- D. Have an infusion pump prepared with oxytocin per protocol for evaluation.
Correct Answer: C
Rationale: The patient should be positioned comfortably, and the tocotransducer should be adjusted to obtain an accurate fetal heart rate reading.
The nurse is caring for a pregnant patient who is 24 weeks gestation and reports nausea, vomiting, and weight loss. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to eat a high-protein diet and avoid fluids during meals.
- B. Encourage the patient to rest and avoid any exercise.
- C. Assess the patient's hydration status and notify the healthcare provider if necessary.
- D. Recommend over-the-counter anti-nausea medications to control symptoms.
Correct Answer: C
Rationale: The correct answer is C: Assess the patient's hydration status and notify the healthcare provider if necessary.
Rationale:
1. Nausea, vomiting, and weight loss in pregnancy may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances.
2. Assessing hydration status is crucial to determine the severity of the condition and guide appropriate interventions.
3. Notifying the healthcare provider allows for further evaluation, possible treatment adjustments, and monitoring to prevent complications.
Summary:
A: Instructing the patient to eat a high-protein diet and avoid fluids during meals does not address the immediate concern of dehydration and may worsen symptoms.
B: Encouraging the patient to rest and avoid exercise is important but does not address the primary issue of dehydration.
D: Recommending over-the-counter anti-nausea medications may provide symptomatic relief but does not address the underlying cause or hydration status.
A pregnant patient at 32 weeks gestation reports occasional dizziness when standing up. What is the nurse's most appropriate recommendation?
- A. Encourage the patient to increase fluid intake and stand up slowly.
- B. Instruct the patient to lie down immediately and rest to prevent fainting.
- C. Advise the patient to avoid physical activity and rest as much as possible.
- D. Instruct the patient to take deep breaths and rise quickly to avoid dizziness.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to increase fluid intake and stand up slowly. This recommendation is appropriate because occasional dizziness when standing up can be due to postural hypotension common in pregnancy. Increasing fluid intake helps maintain blood volume, and standing up slowly prevents sudden drops in blood pressure. Choice B is incorrect as lying down immediately may not address the underlying issue. Choice C is incorrect as complete rest may not be necessary. Choice D is incorrect as rising quickly can worsen dizziness.
A 22-year-old woman presents to the labor and delivery unit in labor at 39 weeks gestation. Her cervix is 6 cm dilated and 100% effaced. What should the nurse do next?
- A. Prepare for delivery
- B. Administer pain relief medications
- C. Continue to monitor contractions and fetal heart rate
- D. Perform a vaginal examination to check for fetal descent
Correct Answer: C
Rationale: The correct answer is C: Continue to monitor contractions and fetal heart rate. At 6 cm dilated and 100% effaced, the woman is in active labor, but delivery is not imminent. Monitoring contractions and fetal heart rate is crucial to ensure the progress of labor and fetal well-being. This step allows the nurse to assess for any signs of fetal distress or labor progression. Administering pain relief medications (B) can be considered based on the woman's pain level, but it is not the immediate priority. Preparing for delivery (A) is premature at this stage. Performing a vaginal examination (D) may not be necessary unless there are concerns about fetal descent or progress of labor.