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The nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with a urinary tract infection (UTI). Which of the following interventions should the nurse prioritize?
- A. Administer antibiotics as prescribed.
- B. Encourage the patient to drink cranberry juice.
- C. Provide education about the signs of preterm labor.
- D. Schedule a follow-up ultrasound to assess fetal health.
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics as prescribed. The priority is to treat the UTI to prevent potential harm to the patient and fetus. Antibiotics are necessary to eliminate the infection and reduce the risk of complications. Encouraging cranberry juice (B) may be beneficial for prevention but is not sufficient to treat an existing UTI. Providing education about preterm labor signs (C) is important but addressing the infection is the immediate concern. Scheduling a follow-up ultrasound (D) may be necessary later but does not address the urgent need to treat the UTI.
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A gravid woman and her husband inform the nurse that they have just moved into a three-story home that was built in the 1930s. Which of the following is critical for the nurse to advise the woman to protect the unborn child?
- A. Stay out of any rooms that are being renovated.
- B. Drink water only from the hot water tap.
- C. Refrain from entering the basement.
- D. Climb the stairs only once per day.
Correct Answer: A
Rationale: Renovations in older homes may release lead dust or asbestos, which are harmful to the developing fetus. Drinking water from the hot tap, limiting stair climbing, or avoiding basements are less critical concerns compared to exposure to renovation hazards.
A nurse is caring for a laboring person who is in the first stage of labor. What is the priority assessment to perform during this stage?
- A. monitor vital signs
- B. perform a vaginal exam
- C. perform a cervical check
- D. monitor the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: monitor vital signs. During the first stage of labor, it is crucial to monitor the laboring person's vital signs to assess for any signs of distress or complications. This includes monitoring blood pressure, pulse rate, respiratory rate, and temperature. By closely monitoring vital signs, the nurse can identify any potential issues early on and take appropriate actions to ensure the safety and well-being of both the laboring person and the baby. Performing a vaginal exam (B) or cervical check (C) may be necessary later in labor but is not the priority assessment during the first stage. Monitoring the fetal heart rate (D) is also important but not the priority over monitoring the laboring person's vital signs.
Which of the following vital sign changes should the nurse highlight for a pregnant woman’s obstetrician?
- A. Prepregnancy blood pressure (BP) 100/60 and third trimester BP 140/90.
- B. Prepregnancy respiratory rate (RR) 16 rpm and third trimester RR 22 rpm.
- C. Prepregnancy heart rate (HR) 76 bpm and third trimester HR 88 bpm.
- D. Prepregnancy temperature (T) 98.6°F and third trimester T 99.2°F.
Correct Answer: A
Rationale: A significant increase in blood pressure, particularly to 140/90, could indicate preeclampsia and should be highlighted for further evaluation. The other changes are within normal limits for pregnancy.
What is the primary nursing action when a laboring person experiences a ruptured uterus?
- A. prepare for an emergency cesarean section
- B. provide immediate pain relief
- C. apply oxygen via mask
- D. apply pressure to the abdomen
Correct Answer: C
Rationale: The correct answer is C: apply oxygen via mask. This is the primary nursing action for a ruptured uterus because it helps improve oxygenation to the laboring person and the fetus. Ruptured uterus can lead to a significant decrease in oxygen supply, so providing oxygen is crucial.
Incorrect choices:
A: preparing for an emergency cesarean section is important but not the primary action in this situation.
B: providing pain relief is important, but ensuring oxygenation is a higher priority.
D: applying pressure to the abdomen is not recommended as it can worsen the condition.
A pregnant patient is at 32 weeks gestation and reports swelling of the feet and legs. What is the most appropriate recommendation for the nurse to make?
- A. Limit fluid intake to reduce swelling.
- B. Elevate the legs and avoid prolonged standing.
- C. Apply compression stockings to improve circulation.
- D. Rest in bed with the feet elevated at all times.
Correct Answer: B
Rationale: The correct answer is B. Elevating the legs and avoiding prolonged standing is the most appropriate recommendation for a pregnant patient experiencing swelling at 32 weeks gestation. Elevating the legs helps to reduce swelling by aiding in venous return and reducing fluid accumulation in the lower extremities. Prolonged standing can worsen swelling due to increased pressure on the veins. Limiting fluid intake (choice A) may lead to dehydration and is not recommended during pregnancy. Applying compression stockings (choice C) may help improve circulation but may not address the underlying cause of swelling. Resting in bed with feet elevated at all times (choice D) is excessive and may not be practical for the patient.