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The nurse is caring for a pregnant patient at 36 weeks gestation who reports sudden, severe headache and blurred vision. What is the nurse's priority action?
- A. Administer pain medication as prescribed to relieve the headache.
- B. Monitor the patient's blood pressure and check for signs of preeclampsia.
- C. Encourage the patient to rest and drink plenty of fluids.
- D. Schedule a follow-up appointment with the healthcare provider for further evaluation.
Correct Answer: B
Rationale: The correct answer is B because sudden severe headache and blurred vision in a pregnant patient at 36 weeks gestation are potential signs of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Monitoring the patient's blood pressure and checking for signs of preeclampsia is crucial for early detection and timely intervention. Administering pain medication (choice A) may mask symptoms and delay appropriate treatment. Encouraging rest and fluids (choice C) may not address the underlying cause of the symptoms. Scheduling a follow-up appointment (choice D) may delay necessary immediate actions to address potential preeclampsia.
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A pregnant patient at 36 weeks gestation reports feeling short of breath when lying flat. What is the nurse's priority action?
- A. Administer oxygen and prepare the patient for delivery.
- B. Encourage the patient to sit up and rest in a more upright position.
- C. Ask the patient to perform deep breathing exercises to improve oxygen flow.
- D. Instruct the patient to take shallow breaths and avoid exertion.
Correct Answer: B
Rationale: The correct answer is B because positioning the pregnant patient in a more upright position can help alleviate the shortness of breath by allowing the diaphragm to move more freely, reducing pressure on the lungs, and improving oxygenation. This action promotes optimal oxygen flow and comfort for the patient.
A: Administering oxygen and preparing for delivery may be necessary in some cases but does not address the immediate need to alleviate shortness of breath caused by the supine position.
C: Deep breathing exercises may not be effective in relieving shortness of breath caused by the supine position and may even exacerbate the discomfort.
D: Instructing the patient to take shallow breaths and avoid exertion does not address the underlying cause of shortness of breath and may not provide adequate relief.
A nurse is assessing a pregnant patient at 36 weeks gestation who complains of pain in the lower abdomen and back. The nurse finds no signs of labor. Which of the following interventions should the nurse implement?
- A. Encourage the patient to rest and monitor for any changes in symptoms.
- B. Administer pain medication and schedule an appointment with the doctor.
- C. Perform a pelvic exam to determine the cause of the pain.
- D. Instruct the patient to remain in bed for the rest of the day.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to rest and monitor for any changes in symptoms. At 36 weeks gestation, the patient might be experiencing Braxton Hicks contractions or round ligament pain, which are common in late pregnancy. Encouraging rest allows for potential relief of discomfort. Monitoring for any changes in symptoms is essential to rule out preterm labor. Option B is incorrect as administering pain medication without identifying the cause may mask symptoms of preterm labor. Option C is incorrect as performing a pelvic exam could potentially cause harm if the patient is experiencing preterm labor. Option D is incorrect as prolonged bed rest is not recommended in pregnancy and may not alleviate the pain or address the underlying cause.
A woman is planning to become pregnant. Which of the following actions should she be counseled to take before stopping birth control? Select all that apply.
- A. Take a daily multivitamin.
- B. See a medical doctor.
- C. Drink beer instead of vodka.
- D. Stop all over-the-counter medications.
Correct Answer: B
Rationale: Taking a multivitamin, consulting a doctor, and stopping potentially harmful medications are important preconception steps. Alcohol consumption should generally be minimized, but switching from vodka to beer is not a significant improvement.
A nurse is caring for a pregnant patient who is 12 weeks gestation and reports feeling fatigued. Which of the following is the nurse's most appropriate response?
- A. Fatigue is normal during the first trimester and should improve in the second trimester.
- B. You should rest as much as possible, but try to get up and move regularly to prevent complications.
- C. Fatigue may indicate an underlying medical condition and should be investigated immediately.
- D. I will prescribe iron supplements to help with your fatigue.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Fatigue is common in the first trimester due to hormonal changes and increased energy demands.
2. Second trimester typically brings relief as hormone levels stabilize and energy levels increase.
3. Reassuring the patient about the normalcy of fatigue promotes understanding and reduces anxiety.
Summary:
- Choice B focuses on rest but does not address the normalcy of fatigue in the first trimester.
- Choice C jumps to conclusions without considering common causes first.
- Choice D assumes iron deficiency without assessing the patient's overall health status.
The nurse is caring for a pregnant patient who is 36 weeks gestation and is concerned about preterm labor. Which of the following is a key sign of preterm labor?
- A. Regular contractions every 10 minutes or less
- B. Decreased fetal movement
- C. Mild cramping and back pain
- D. Increased energy levels and appetite
Correct Answer: A
Rationale: The correct answer is A: Regular contractions every 10 minutes or less. This is a key sign of preterm labor because regular contractions at this frequency could indicate the onset of labor before the full term. Contractions help to thin and dilate the cervix, leading to the birth of the baby. Decreased fetal movement (B) is a concerning sign but not a definitive indicator of preterm labor. Mild cramping and back pain (C) can be common in pregnancy and may not necessarily indicate preterm labor. Increased energy levels and appetite (D) are not typical signs of preterm labor, as the body usually shows signs of preparing for labor rather than increased energy levels.