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The nurse is caring for a 35-year-old woman who is pregnant and has a history of hypertension. Which intervention would be most important to prevent preeclampsia?
- A. Encourage regular physical activity and a healthy diet.
- B. Monitor the patient's weight gain and blood pressure.
- C. Prescribe antihypertensive medications immediately.
- D. Avoid any further prenatal visits to prevent stress.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's weight gain and blood pressure. Monitoring weight gain and blood pressure is crucial to detect early signs of preeclampsia in pregnant women with a history of hypertension. Weight gain can indicate fluid retention, a common symptom of preeclampsia, while high blood pressure is a key indicator of the condition. By closely monitoring these parameters, the nurse can promptly identify and manage preeclampsia to prevent complications for both the mother and the baby.
Incorrect choices:
A: Encouraging regular physical activity and a healthy diet is important for overall health but may not directly prevent preeclampsia.
C: Prescribing antihypertensive medications immediately may be necessary if blood pressure is severely elevated, but it is not the most important intervention for preventing preeclampsia.
D: Avoiding prenatal visits to prevent stress is not a valid approach as regular prenatal care is essential for monitoring the pregnancy and managing any complications that may
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The nurse is educating a pregnant patient on the importance of maintaining a balanced diet during pregnancy. Which of the following statements by the patient indicates effective teaching?
- A. I should avoid all carbohydrates to prevent gestational diabetes.
- B. I need to eat extra food for my baby to ensure proper growth.
- C. I will eat a variety of nutrient-dense foods and avoid processed foods.
- D. I can focus on eating as much protein as possible to support my baby's development.
Correct Answer: C
Rationale: Rationale: Choice C is correct because it emphasizes the importance of eating a variety of nutrient-dense foods and avoiding processed foods. This approach ensures the pregnant patient receives essential nutrients for her health and the baby's development. Variety helps cover all necessary nutrients, while avoiding processed foods reduces the intake of unhealthy additives. This balanced diet promotes optimal health outcomes for both the mother and the baby.
Summary of Incorrect Choices:
A: Avoiding all carbohydrates is not recommended as they are a vital energy source and cutting them out completely can lead to nutritional deficiencies.
B: Eating extra food indiscriminately can result in excessive weight gain and complications. The focus should be on nutrient-dense foods, not just quantity.
D: Focusing solely on protein neglects other important nutrients needed during pregnancy. A well-rounded diet is essential for overall health.
A client enters the prenatal clinic. She states that she missed her period yesterday and used a home pregnancy test this morning. She states that the results were negative, but 'I still think I am pregnant.' Which of the following statements would be appropriate for the nurse to make at this time?
- A. Your period is probably just irregular.
- B. We could do a blood test to check.
- C. Home pregnancy test results are very accurate.
- D. My recommendation would be to repeat the test in one week.
Correct Answer: B
Rationale: A blood test is more accurate than a home pregnancy test, especially early in pregnancy. Repeating the test in a week is also an option, but a blood test provides more immediate and reliable results.
A pregnant patient is at 30 weeks gestation and is experiencing difficulty breathing, especially when lying flat. What is the nurse's priority action?
- A. Encourage the patient to rest in an upright position.
- B. Administer oxygen and prepare the patient for delivery.
- C. Monitor the fetal heart rate for signs of distress.
- D. Instruct the patient to take deep breaths and stay in bed.
Correct Answer: A
Rationale: The correct answer is A - Encourage the patient to rest in an upright position. This is the priority action because the patient is likely experiencing supine hypotensive syndrome due to pressure on the vena cava when lying flat. This can compromise blood flow to the fetus. By having the patient rest in an upright position, the pressure on the vena cava is reduced, improving blood flow and oxygenation for both the patient and the fetus. Administering oxygen and preparing for delivery (option B) is not the immediate priority. Monitoring fetal heart rate (option C) is important but not the initial action. Instructing the patient to take deep breaths and stay in bed (option D) does not address the underlying issue of supine hypotensive syndrome.
The nurse is caring for a pregnant patient who is 38 weeks gestation and reports feeling pelvic pressure and mild cramping. What should the nurse do first?
- A. Monitor the fetal heart rate and check for signs of labor.
- B. Instruct the patient to rest and monitor the symptoms.
- C. Assess the patient's blood pressure and urine for protein.
- D. Perform a pelvic exam to assess for cervical dilation.
Correct Answer: A
Rationale: The correct answer is A because monitoring the fetal heart rate and checking for signs of labor are essential in assessing the well-being of the fetus and determining if the patient is in active labor. This step helps the nurse identify any potential complications and take appropriate actions promptly.
Choice B is incorrect because simply instructing the patient to rest may not address the underlying cause of pelvic pressure and cramping.
Choice C is incorrect as assessing blood pressure and urine for protein is not the priority in this situation.
Choice D is incorrect because performing a pelvic exam should be done after monitoring fetal well-being and ruling out active labor.
A pregnant woman who is 36 weeks gestation reports sudden swelling in her hands and feet, along with a headache. What should the nurse do first?
- A. Instruct the patient to rest and elevate her feet.
- B. Assess the patient's blood pressure and urine for protein.
- C. Encourage the patient to drink plenty of fluids.
- D. Recommend that the patient lie on her left side to improve circulation.
Correct Answer: B
Rationale: The correct answer is B. Assessing the patient's blood pressure and urine for protein is the priority because sudden swelling in hands and feet, along with a headache, could indicate preeclampsia, a serious condition in pregnancy. High blood pressure and protein in the urine are key indicators of preeclampsia. This assessment will help determine if the patient needs immediate medical intervention.
Choice A is incorrect because simply resting and elevating the feet may not address the underlying issue of preeclampsia. Choice C is incorrect as encouraging the patient to drink fluids will not address the potential serious condition. Choice D is incorrect because while lying on the left side can improve circulation, it does not address the urgent need to assess for preeclampsia.