Nokea
The nurse is assessing a pregnant patient who is 30 weeks gestation and reports pain in the lower abdomen and back. What should the nurse do first?
- A. Assess for signs of preterm labor, including regular contractions.
- B. Administer pain medication and advise the patient to rest.
- C. Encourage the patient to perform light physical activity to relieve the pain.
- D. Instruct the patient to lie flat on her back and monitor the symptoms.
Correct Answer: A
Rationale: The correct answer is A because pain in the lower abdomen and back could indicate preterm labor at 30 weeks gestation. The first step is to assess for signs of preterm labor, such as regular contractions, to determine the urgency of the situation. Administering pain medication (B) without assessing the cause can mask symptoms. Encouraging physical activity (C) may worsen preterm labor. Instructing the patient to lie flat on her back (D) can decrease blood flow to the uterus and is not recommended in late pregnancy.
You may also like to solve these questions
Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following?
- A. Avoid eating greasy foods.
- B. Drink orange juice before rising.
- C. Consume 1 teaspoon of nutmeg each morning.
- D. Eat 3 large meals plus a bedtime snack.
Correct Answer: A
Rationale: Greasy foods can exacerbate nausea and vomiting. Small, frequent meals are recommended, and saltine crackers before rising can help alleviate symptoms. Orange juice and nutmeg are not recommended.
What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the uterine wall?
- A. Amnion
- B. Yolk sac
- C. Chorion
- D. Decidua basalis
Correct Answer: C
Rationale: The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.
What alternative could the nurse suggest to someone practicing pica?
- A. Replace laundry starch with salt
- B. Replace ice with frozen fruit juice
- C. Replace soap with cream cheese
- D. Replace soil with uncooked pie crust
Correct Answer: B
Rationale: Replacing ice with frozen fruit juice provides a safer alternative while satisfying the craving for cold substances.
A nurse is educating a pregnant patient on the importance of folic acid. Which of the following statements by the patient indicates that the teaching has been effective?
- A. I will take folic acid throughout my entire pregnancy to support fetal development.
- B. I will start taking folic acid after the first trimester to help prevent birth defects.
- C. I should only take folic acid if I have a family history of birth defects.
- D. Folic acid will help reduce the risk of gestational diabetes and hypertension.
Correct Answer: A
Rationale: The correct answer is A because taking folic acid throughout the entire pregnancy is crucial for supporting fetal development, especially in the early stages when the neural tube is forming. This statement reflects the patient's understanding of the importance of consistent folic acid intake during pregnancy.
Choice B is incorrect because waiting until after the first trimester misses the critical period when the neural tube develops. Choice C is incorrect as folic acid is recommended for all pregnant women regardless of family history. Choice D is incorrect because while folic acid is beneficial for fetal development, it is not specifically linked to reducing the risk of gestational diabetes or hypertension.
During the postpartum period, a nurse is caring for a birthing person who is receiving uterotonic medications. The nurse's assessment reveals a boggy and enlarged uterus. What is the nurse's immediate action?
- A. Document the findings as normal.
- B. Continue to administer the uterotonic medication.
- C. Perform fundal massage to promote uterine firmness.
- D. Administer an analgesic for the birthing person's pain.
Correct Answer: C
Rationale: The correct immediate action is C: Perform fundal massage to promote uterine firmness. Fundal massage helps prevent postpartum hemorrhage by promoting uterine contraction and firmness. A: Documenting the findings as normal is incorrect as a boggy and enlarged uterus is not a normal finding postpartum. B: Continuing to administer uterotonic medication without addressing the boggy uterus can lead to ineffective contraction. D: Administering an analgesic for pain does not address the underlying issue of uterine atony.