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The nurse is caring for a pregnant patient who is 22 weeks gestation and has a history of gestational hypertension. What should the nurse monitor most closely?
- A. Blood glucose levels to check for gestational diabetes
- B. Protein in the urine to assess for preeclampsia
- C. Fetal heart rate to check for signs of fetal distress
- D. Daily weight gain to assess for fluid retention
Correct Answer: B
Rationale: The correct answer is B: Protein in the urine to assess for preeclampsia. The nurse should closely monitor protein in the urine because the patient has a history of gestational hypertension, which puts her at risk for developing preeclampsia. Preeclampsia is characterized by high blood pressure and proteinuria. Monitoring protein in the urine helps detect early signs of preeclampsia, which can lead to serious complications for both the mother and the fetus if left untreated.
Blood glucose levels (A) are not the priority in this case, as the patient's history indicates a higher risk for preeclampsia. Fetal heart rate (C) and daily weight gain (D) are important aspects to monitor during pregnancy; however, in this scenario, the focus should be on detecting signs of preeclampsia due to the patient's history of gestational hypertension.
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During open glottis pushing, what is the laboring person instructed to do?
- A. hold their breath and push for 10 seconds during each contraction
- B. push spontaneously while exhaling during contractions
- C. exhale slowly during contractions without pushing
- D. perform deep breathing exercises between contractions
Correct Answer: B
Rationale: During open glottis pushing, the correct instruction is for the laboring person to push spontaneously while exhaling during contractions (Choice B). This technique helps prevent breath-holding, which can increase intra-abdominal pressure and reduce blood flow to the heart and baby. Exhaling while pushing allows for better oxygenation and reduces the risk of Valsalva maneuver-related complications. Holding their breath (Choice A) can increase the risk of fetal distress. Exhaling slowly without pushing (Choice C) is not effective in assisting with the pushing stage of labor. Deep breathing exercises between contractions (Choice D) are beneficial for relaxation but not the main focus during pushing.
The nurse is caring for a pregnant patient who is 30 weeks gestation and reports feeling faint and lightheaded. What is the most appropriate action for the nurse to take?
- A. Instruct the patient to lie on her back to improve circulation.
- B. Encourage the patient to take deep breaths and sit down immediately.
- C. Instruct the patient to stand up slowly and rest for 10 minutes.
- D. Ask the patient to eat something sweet to raise her blood sugar.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to take deep breaths and sit down immediately. This action is appropriate because the patient is experiencing symptoms of hypotension, which can lead to decreased blood flow to the brain causing faintness and lightheadedness. By encouraging the patient to take deep breaths and sit down immediately, the nurse is helping to increase oxygen intake and improve circulation, which can alleviate the symptoms.
Explanation for why the other choices are incorrect:
A: Instructing the patient to lie on her back can actually worsen symptoms as it can lead to a decrease in blood flow to the brain.
C: Instructing the patient to stand up slowly is not appropriate as the patient is already feeling faint and lightheaded. This can increase the risk of falling and injury.
D: Asking the patient to eat something sweet may not address the underlying cause of the symptoms, which is likely related to hypotension. It is important to address the immediate
A nurse is educating a pregnant patient at 32 weeks gestation about safe physical activity. Which of the following recommendations should the nurse prioritize?
- A. Perform strenuous exercise to strengthen muscles and improve endurance.
- B. Engage in moderate exercise, such as walking or swimming, to maintain health.
- C. Avoid all physical activity during pregnancy to reduce the risk of complications.
- D. Engage in high-impact exercises to strengthen bones and joints.
Correct Answer: B
Rationale: The correct answer is B because engaging in moderate exercise like walking or swimming is recommended for pregnant patients at 32 weeks gestation. This type of activity helps maintain health without putting excessive strain on the body. Strenuous exercises (Choice A) may increase the risk of injury or complications during pregnancy. Avoiding all physical activity (Choice C) can lead to decreased muscle tone and potential complications. High-impact exercises (Choice D) can be too harsh on the joints and bones during pregnancy. Therefore, moderate exercise is the safest and most beneficial option for pregnant patients at this stage.
Five minutes after delivery of the infant, the umbilical cord is protruding more from the woman's vaginal introitus and there is a sudden gush of blood with a contracted uterus. What does this signal to the nurse?
- A. Laceration of the genital tract
- B. The second stage of labor
- C. Separation of the placenta
- D. Postpartum hemorrhage
Correct Answer: C
Rationale: The sudden gush of blood and the contracted uterus indicate a separation of the placenta, which is a serious complication called placental abruption. This condition can lead to significant bleeding and jeopardize the health of both the mother and the baby. It is essential for the nurse to recognize this situation promptly and take immediate action to manage the hemorrhage and stabilize the patient.
Explanation for incorrect choices:
A: Laceration of the genital tract would not typically cause a sudden gush of blood and a contracted uterus.
B: The second stage of labor is characterized by the delivery of the baby, not by a sudden gush of blood and a contracted uterus.
D: Postpartum hemorrhage could be a consequence of placental separation, but it is not the primary issue indicated by the symptoms described in the scenario.
A nurse is caring for a laboring person who is experiencing late decelerations in fetal heart rate. What is the priority nursing intervention?
- A. place the person on their left side
- B. apply oxygen via mask
- C. administer pain medication
- D. perform a vaginal examination
Correct Answer: A
Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.