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The nurse is assessing a client in the third trimester who reports headaches and blurred vision. What is the priority nursing action?
- A. Check the client's blood pressure.
- B. Assess fetal heart rate.
- C. Administer acetaminophen as prescribed.
- D. Encourage the client to lie down and rest.
Correct Answer: A
Rationale: Headaches and blurred vision can be symptoms of preeclampsia, making blood pressure assessment a priority.
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A patient calls the clinic Monday morning. She had condomless sex Friday night and is interested in emergency contraception. What should the nurse tell this patient?
- A. Emergency contraception pills are very effective for medically induced abortions early in pregnancy.
- B. If she is not midcycle when she had sex, she does not need emergency contraception.
- C. It is too late for her to use emergency contraceptive pills, but she can come in for placement of a copper IUD.
- D. She can use emergency contraceptive pills, even if she has had other condomless sex since the Friday night event.
Correct Answer: D
Rationale: The correct advice for the patient in this scenario is to inform her that she can still use emergency contraceptive pills, even if she has had other condomless sex since the Friday night event. Emergency contraceptive pills are most effective when taken as soon as possible after unprotected sex, but they can still be used within a certain window of time depending on the type of pill used. It is important to inform the patient that she can take emergency contraception in this situation to reduce the risk of an unintended pregnancy.
What is the purpose of a birth plan?
- A. dream about birth
- B. learn about birth options and determine personal preferences
- C. list all things not wanted for the birth
- D. ensure an unmedicated birth
Correct Answer: B
Rationale: A birth plan helps individuals explore options and articulate their preferences for childbirth.
A client at 12 weeks' gestation asks why folic acid is important during pregnancy. What is the nurse's best response?
- A. It helps prevent gestational diabetes.
- B. It promotes fetal brain development.
- C. It reduces the risk of neural tube defects.
- D. It increases maternal energy levels.
Correct Answer: C
Rationale: Folic acid is essential during early pregnancy to reduce the risk of neural tube defects like spina bifida.
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
- A. Strict bed rest is required after the procedure.
- B. Hospitalization is necessary for 24 hours after the procedure.
- C. An informed consent needs to be signed before the procedure.
- D. A fever is expected after the procedure because of the trauma to the abdomen.
Correct Answer: C
Rationale: Informed consent is essential before an invasive procedure like amniocentesis. Monitoring post-procedure symptoms is also crucial.
The nurse is preparing a client for cesarean delivery. What is the priority nursing action?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Verify signed informed consent.
- D. Administer prophylactic antibiotics.
Correct Answer: C
Rationale: Ensuring informed consent is signed is a priority before any surgical procedure.