Nokea
The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?
- A. Inadequate space in the uterus
- B. Inadequate blood supply
- C. Inadequate maternal health
- D. Inadequate placental nutrition
Correct Answer: D
Rationale: The single placenta may not be able to provide adequate nutrition to two fetuses.
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The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?
- A. Fetal heart rate via Doppler.
- B. Positive pregnancy test.
- C. Positive Chadwick’s sign.
- D. Montgomery gland enlargements.
Correct Answer: A
Rationale: A fetal heart rate detected via Doppler is a positive sign of pregnancy. A positive pregnancy test, Chadwick’s sign, and Montgomery gland enlargements are probable signs but not definitive.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
- A. Magnesium sulfate
- B. Prostaglandin suppository
- C. RhoGAM if the patient is Rh-negative
- D. Betamethasone
Correct Answer: C
Rationale: Rh-negative women undergoing CVS require RhoGAM to prevent Rh sensitization.
A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immediately if she experiences which of the following signs/symptoms? Select all that apply.
- A. Convulsions.
- B. Double vision.
- C. Epigastric pain.
- D. Persistent vomiting.
Correct Answer: D
Rationale: These symptoms may indicate severe complications such as preeclampsia, eclampsia, or hyperemesis gravidarum, requiring immediate medical attention. Polyuria is generally not a danger sign.
A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
- A. Instruct the patient to avoid standing for long periods.
- B. Encourage the patient to increase sodium intake.
- C. Recommend that the patient take frequent naps during the day.
- D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.
A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.
A pregnant patient at 36 weeks gestation reports feeling short of breath when lying flat. What is the most appropriate recommendation for the nurse to make?
- A. Encourage the patient to lie on her left side to improve circulation.
- B. Administer oxygen as prescribed to alleviate breathing difficulties.
- C. Instruct the patient to rest in an upright position to reduce pressure on the diaphragm.
- D. Advise the patient to take deep breaths and monitor symptoms.
Correct Answer: C
Rationale: The correct answer is C because instructing the patient to rest in an upright position helps reduce pressure on the diaphragm, allowing for better lung expansion and improved breathing capacity. This position can alleviate the shortness of breath experienced when lying flat due to the growing uterus pressing on the diaphragm. Option A is incorrect because lying on the left side may not alleviate the pressure on the diaphragm as effectively as an upright position. Option B may provide temporary relief but does not address the underlying cause. Option D focuses on symptom management rather than addressing the positional discomfort caused by the pregnancy.