Nokea
The nurse is caring for a 14-year-old patient who is 32 weeks pregnant. After complaining of genital sores and discomfort, the patient tests positive for syphilis. The fetus is at increased risk of which condition?
- A. Diabetes
- B. Blindness
- C. Pneumonia
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Blindness. Syphilis infection during pregnancy can lead to congenital syphilis, which can cause a range of complications for the fetus, including blindness. The spirochete that causes syphilis can cross the placenta and affect the developing fetus, leading to various abnormalities. Blindness is a common manifestation of congenital syphilis due to damage to the eyes and optic nerve. The other options are not directly associated with syphilis infection during pregnancy. Diabetes, pneumonia, and hypertension are not typically linked to congenital syphilis and its effects on the fetus. Therefore, the correct answer is B: Blindness.
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A pregnant patient is 36 weeks gestation and reports increased vaginal discharge. What is the nurse's priority action?
- A. Assess the nature of the discharge for signs of infection.
- B. Instruct the patient to monitor the discharge at home.
- C. Recommend the patient use panty liners to manage the discharge.
- D. Provide education about normal pregnancy changes, including discharge.
Correct Answer: A
Rationale: The correct answer is A: Assess the nature of the discharge for signs of infection. At 36 weeks gestation, increased vaginal discharge could be a sign of infection, such as bacterial vaginosis or yeast infection, which can lead to preterm labor. The nurse's priority is to assess for infection to prevent any potential harm to the mother and baby. By assessing the nature of the discharge, the nurse can determine if further evaluation or treatment is needed.
Choice B is incorrect because instructing the patient to monitor the discharge at home does not address the potential seriousness of the situation. Choice C is incorrect as using panty liners only manages the symptom without addressing the underlying cause. Choice D is incorrect because providing education about normal pregnancy changes does not address the immediate need to rule out infection in this scenario.
A nurse is preparing a laboring person for an emergency cesarean birth. What is the most important nursing intervention prior to the procedure?
- A. administer a preoperative medication
- B. administer pain relief
- C. administer an epidural block
- D. administer IV fluids
Correct Answer: A
Rationale: The correct answer is A: administer a preoperative medication. This is crucial prior to an emergency cesarean birth to ensure the person is adequately prepared for the procedure. Preoperative medications can help reduce anxiety, prevent complications such as aspiration during anesthesia induction, and promote smooth recovery post-surgery. Administering pain relief (B) and epidural block (C) may be important for comfort but are not the priority in this urgent situation. Administering IV fluids (D) is generally important in preparation for surgery, but administering preoperative medication takes precedence in this scenario to ensure the person's safety and well-being during the emergency cesarean birth.
A pregnant patient at 36 weeks gestation is experiencing swelling in her hands and feet. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Instruct the patient to rest and elevate her legs regularly.
- C. Advise the patient to drink more water and reduce sodium intake.
- D. Encourage the patient to take a warm bath to reduce swelling.
Correct Answer: A
Rationale: The correct answer is A. At 36 weeks gestation, swelling in the hands and feet could be a sign of preeclampsia, a serious condition. The nurse's priority is to monitor the patient's blood pressure and assess for other signs of preeclampsia, such as headache, visual disturbances, and proteinuria. Prompt detection and management of preeclampsia are crucial to prevent complications like eclampsia and HELLP syndrome. Choices B, C, and D do not address the potential seriousness of the situation and may delay the necessary assessment and intervention for preeclampsia.
A nurse is assessing a postpartum person for signs of urinary retention. What is the most common sign of urinary retention in the postpartum period?
- A. Abdominal distension
- B. Frequent voiding
- C. No voiding for several hours
- D. Urinary urgency
Correct Answer: C
Rationale: The correct answer is C: No voiding for several hours. Postpartum urinary retention is common due to trauma during childbirth. The bladder may be unable to contract effectively, leading to a lack of sensation to void. This can result in no voiding for several hours. Abdominal distension (A) is not specific to urinary retention. Frequent voiding (B) and urinary urgency (D) are not characteristic signs of urinary retention; they are more indicative of overactive bladder or urinary tract infection.
A 32-week pregnant woman is admitted to the hospital in preterm labor. What is the most appropriate intervention to delay delivery?
- A. Administer corticosteroids to promote fetal lung development
- B. Provide an epidural for pain management
- C. Give magnesium sulfate to inhibit uterine contractions
- D. Begin oxytocin infusion to speed up labor
Correct Answer: C
Rationale: The correct answer is C: Give magnesium sulfate to inhibit uterine contractions. Magnesium sulfate is used to delay preterm labor by relaxing the uterine muscles, thus decreasing contractions. This intervention helps to delay delivery and give time for other interventions to be implemented, such as administering corticosteroids to promote fetal lung development. Providing an epidural for pain management (B) does not address the issue of preterm labor. Beginning oxytocin infusion (D) would speed up labor, which is not appropriate in this scenario. Administering corticosteroids (A) is a beneficial intervention but should be done after delaying delivery with magnesium sulfate.