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Place these developmental milestones in chronological order: Four-chambered heart forms, Vernix caseosa appears, Blastocyst development completes, Testes descend
- A. Blastocyst development complete
- B. Four-chambered heart forms
- C. Vernix caseosa present
- D. Testes descend into scrotum
Correct Answer: B
Rationale: Development follows the sequence: blastocyst formation, four-chambered heart, vernix appearance, and testicular descent.
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A pregnant patient at 28 weeks gestation reports lower back pain. What should the nurse do first?
- A. Administer pain medication and encourage rest.
- B. Assess the patient's posture and recommend appropriate exercises.
- C. Instruct the patient to lie flat on her back to relieve pain.
- D. Perform a pelvic exam to check for any underlying complications.
Correct Answer: B
Rationale: The correct answer is B because assessing the patient's posture and recommending appropriate exercises can help alleviate lower back pain during pregnancy. Poor posture and lack of exercise are common causes of back pain in pregnancy. Administering pain medication as in choice A may not address the root cause. Instructing the patient to lie flat on her back (choice C) can actually worsen back pain and pose risks during pregnancy. Performing a pelvic exam (choice D) is not necessary unless there are specific indications for it related to the patient's complaint. Therefore, choice B is the most appropriate initial action to address the lower back pain in this pregnant patient.
A nurse is caring for a 38-week pregnant patient who is experiencing a decrease in fetal movement. Which of the following should be the nurse's first action?
- A. Encourage the patient to drink a cold beverage and lie down.
- B. Instruct the patient to wait 24 hours and monitor fetal movements.
- C. Order an ultrasound to check the baby's health.
- D. Call the healthcare provider immediately to report the decrease in movement.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a cold beverage and lie down. This is the correct action as it promotes fetal movement by stimulating the baby with a change in temperature and position. It is a non-invasive and immediate measure that can be taken by the patient herself.
Choice B is incorrect because waiting 24 hours could delay necessary intervention if the fetus is in distress. Choice C is incorrect as ordering an ultrasound may not be the most immediate or necessary action at this point. Choice D is incorrect as calling the healthcare provider immediately may not be necessary if the issue can be resolved by the patient changing her position and trying to stimulate fetal movement first.
A nurse is preparing a laboring person for an epidural. What is the most important intervention before the procedure?
- A. ensure informed consent
- B. assist with proper positioning
- C. check for allergies to anesthesia
- D. educate on wound care
Correct Answer: C
Rationale: The correct answer is C: check for allergies to anesthesia. Before administering an epidural, it is crucial to check for any allergies to anesthesia to prevent potential allergic reactions. This step ensures the safety and well-being of the laboring person. Informed consent (choice A) is important but not the most critical step before an epidural. Proper positioning (choice B) is essential during the procedure but not the top priority before it. Educating on wound care (choice D) is not directly relevant to preparing for an epidural.
A nurse is caring for a pregnant patient who is 30 weeks gestation and is diagnosed with mild preeclampsia. Which of the following should be included in the plan of care?
- A. Administer magnesium sulfate to prevent seizures.
- B. Monitor blood pressure and assess for protein in the urine.
- C. Encourage rest and restricted activity to lower blood pressure.
- D. Perform daily blood glucose monitoring for gestational diabetes.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood pressure and assess for protein in the urine. This is crucial in the care of a pregnant patient with mild preeclampsia at 30 weeks gestation. Monitoring blood pressure helps in assessing the severity of the condition and guiding treatment. Assessing for protein in the urine confirms the diagnosis and helps in monitoring kidney function and overall disease progression.
Explanation of why the other choices are incorrect:
A: Administering magnesium sulfate is typically indicated for severe preeclampsia to prevent seizures, not mild preeclampsia.
C: Encouraging rest and restricted activity can help manage symptoms but is not a primary intervention for mild preeclampsia.
D: Daily blood glucose monitoring is important for gestational diabetes, not specifically for mild preeclampsia.
The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix?
- A. They are destroyed by the acidic pH of the vagina.
- B. They survive up to 5 days and can cause pregnancy.
- C. They lose their motility in about 12 hours after intercourse.
- D. They are usually pushed out of the vagina by the muscular action of the vaginal wall.
Correct Answer: B
Rationale: Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.