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The nurse is caring for a pregnant patient at 24 weeks gestation who reports increased vaginal discharge. What should the nurse do first?
- A. Assess the characteristics of the discharge, including color and odor.
- B. Encourage the patient to rest and monitor for changes in discharge.
- C. Instruct the patient to wear a sanitary pad and track the amount of discharge.
- D. Perform a pelvic exam to check for signs of infection or complications.
Correct Answer: A
Rationale: Rationale:
Step 1: Assess characteristics of discharge - determining color and odor helps identify if it's normal or concerning.
Step 2: Based on assessment, decide next steps - presence of abnormal color or odor may indicate infection or other issues.
Step 3: Implement appropriate interventions - further evaluation or treatment as needed.
Summary:
- B: Resting and monitoring alone may not address the underlying cause of increased discharge.
- C: While tracking amount is important, it doesn't provide immediate information on potential infection.
- D: Performing a pelvic exam should come after initial assessment of discharge characteristics to guide further actions.
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A nurse is assisting with a vaginal delivery. What is the most important intervention when the head begins to crown?
- A. apply gentle downward pressure
- B. apply upward pressure
- C. assist with positioning
- D. assist with perineal massage
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps prevent rapid delivery to avoid perineal tearing and allows controlled stretching of the perineum. Applying upward pressure (B) can increase the risk of tearing. Positioning (C) is important but not the most critical at this stage. Perineal massage (D) is typically done before crowning, not during.
The nurse is caring for a pregnant patient who is 24 weeks gestation and reports feeling dizzy when standing. What should the nurse recommend to the patient?
- A. Take deep breaths and stand up quickly to relieve dizziness.
- B. Sit down and drink a cold beverage to improve circulation.
- C. Lie flat on your back immediately to prevent fainting.
- D. Rise slowly from a seated or lying position and avoid standing for long periods.
Correct Answer: D
Rationale: The correct answer is D. When a pregnant patient feels dizzy, it can be due to postural hypotension. Rising slowly helps prevent a sudden drop in blood pressure. Standing for long periods can worsen symptoms. Option A is incorrect as standing up quickly can exacerbate dizziness. Option B is incorrect as cold beverages do not address the underlying issue. Option C is incorrect as lying flat on the back can decrease blood flow to the uterus.
The nurse is assessing a pregnant patient who is 30 weeks gestation and reports severe lower back pain. What is the most appropriate intervention for the nurse to recommend?
- A. Instruct the patient to lie flat on her back to relieve pain.
- B. Encourage the patient to perform gentle stretching exercises and maintain good posture.
- C. Encourage the patient to rest in bed and avoid any physical activity.
- D. Recommend taking over-the-counter pain medication to alleviate discomfort.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to perform gentle stretching exercises and maintain good posture. This option promotes active management of lower back pain in pregnancy by improving muscle strength and flexibility, reducing strain on the back. Stretching exercises can help alleviate discomfort and improve posture, which are important for managing back pain during pregnancy. Option A is incorrect as lying flat on the back is contraindicated in pregnancy due to the risk of supine hypotensive syndrome. Option C is incorrect as complete bed rest is not recommended for back pain management. Option D is incorrect as over-the-counter pain medication should be used judiciously during pregnancy and is not the first-line intervention for managing back pain.
A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate?
- A. That is very exciting. The baby must be very healthy.
- B. Would you please describe what you felt for me?
- C. That is impossible. The baby is not big enough yet.
- D. Would you please let me see if I can feel the baby?
Correct Answer: B
Rationale: At 10 weeks, fetal movement is unlikely to be felt. The nurse should ask the client to describe what she felt to determine if it was indeed fetal movement or another sensation.
The nurse is caring for a pregnant patient who is experiencing leg swelling. Which of the following actions should the nurse encourage to reduce the swelling?
- A. Limit physical activity and avoid standing for long periods.
- B. Increase sodium intake to help retain water and reduce swelling.
- C. Wear tight compression stockings to improve circulation.
- D. Elevate the legs and avoid crossing them while sitting.
Correct Answer: D
Rationale: The correct answer is D. Elevating the legs and avoiding crossing them while sitting helps reduce swelling by promoting venous return and improving circulation. Elevating the legs above the heart level assists in reducing edema. Choices A and C are incorrect as limiting physical activity and wearing tight compression stockings may not effectively address the underlying issue of poor circulation. Choice B is also incorrect as increasing sodium intake can lead to fluid retention and worsen swelling.