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
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The nurse is teaching a pregnant patient about prenatal vitamins. Which statement by the patient indicates that further teaching is needed?
- A. I will take these vitamins every day as prescribed.
- B. I will stop taking these vitamins if I feel nauseous.
- C. I should take prenatal vitamins to help prevent birth defects.
- D. These vitamins will help my baby grow and develop properly.
Correct Answer: B
Rationale: The correct answer is B. The rationale is that stopping prenatal vitamins if feeling nauseous can deprive the baby of essential nutrients crucial for proper development. Nausea is common during pregnancy, and it's important to continue taking prenatal vitamins to ensure the baby receives necessary nutrients. Choices A, C, and D all demonstrate understanding of the importance of prenatal vitamins in supporting the baby's growth and preventing birth defects.
The nurse is caring for a 14-year-old patient who is 32 weeks pregnant. After complaining of genital sores and discomfort, the patient tests positive for syphilis. The fetus is at increased risk of which condition?
- A. Diabetes
- B. Blindness
- C. Pneumonia
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Blindness. Syphilis infection during pregnancy can lead to congenital syphilis, which can cause a range of complications for the fetus, including blindness. The spirochete that causes syphilis can cross the placenta and affect the developing fetus, leading to various abnormalities. Blindness is a common manifestation of congenital syphilis due to damage to the eyes and optic nerve. The other options are not directly associated with syphilis infection during pregnancy. Diabetes, pneumonia, and hypertension are not typically linked to congenital syphilis and its effects on the fetus. Therefore, the correct answer is B: Blindness.
A nurse is caring for a pregnant patient at 34 weeks gestation who has been diagnosed with gestational hypertension. What is the nurse's priority intervention?
- A. Encourage the patient to rest and increase fluid intake.
- B. Monitor the patient's blood pressure regularly and assess for signs of preeclampsia.
- C. Administer antihypertensive medications as prescribed.
- D. Instruct the patient to lie on her back to relieve pressure on the uterus.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure regularly and assess for signs of preeclampsia. At 34 weeks gestation with gestational hypertension, monitoring blood pressure and assessing for signs of preeclampsia are crucial to detect any worsening condition. Preeclampsia is a serious complication of gestational hypertension that can lead to adverse outcomes for both the mother and fetus. Regular monitoring allows for timely intervention if necessary.
Choice A is incorrect because simply encouraging rest and increased fluid intake may not address the potential severity of gestational hypertension and preeclampsia.
Choice C is incorrect because administering antihypertensive medications without proper monitoring and assessment can be harmful to the patient and fetus.
Choice D is incorrect because lying on her back can actually worsen the patient's condition by decreasing blood flow to the uterus.
The nurse is caring for a pregnant patient who is 36 weeks gestation and is concerned about the upcoming delivery. Which of the following statements by the nurse is most appropriate?
- A. Labor will likely be quick and easy, especially since this is your first pregnancy.
- B. Labor can be unpredictable, and each birth is different.
- C. You will probably need a cesarean section since you are at full term.
- D. You may not feel any pain during labor because of modern pain relief options.
Correct Answer: B
Rationale: The correct answer is B: "Labor can be unpredictable, and each birth is different." This response acknowledges the variability and individuality of labor experiences, providing reassurance to the patient. Labor outcomes depend on various factors such as maternal health, baby's position, and other unforeseen circumstances.
Explanation:
1. A (Labor will likely be quick and easy, especially since this is your first pregnancy): This statement is incorrect because the duration and ease of labor are not solely determined by the patient's parity (number of pregnancies). Each labor is unique and may vary in length and intensity regardless of previous pregnancies.
2. C (You will probably need a cesarean section since you are at full term): This statement is incorrect as the majority of pregnant women deliver vaginally at full term. Cesarean section is not a predetermined outcome solely based on gestational age.
3. D (You may not feel any pain during labor because of modern pain relief options): This statement is incorrect because pain
A nurse is caring for a laboring person who is in the second stage of labor. What is the most important action to promote fetal descent?
- A. coach the person through controlled pushing
- B. increase maternal hydration
- C. provide comfort measures
- D. apply gentle pressure to the abdomen
Correct Answer: A
Rationale: The correct answer is A: coach the person through controlled pushing. This is the most important action to promote fetal descent during the second stage of labor because pushing helps the baby move through the birth canal. Controlled pushing helps prevent exhaustion and reduces the risk of maternal injury. Increasing maternal hydration (choice B) is important for overall well-being but does not directly promote fetal descent. Comfort measures (choice C) are important for pain management but do not directly aid in fetal descent. Applying gentle pressure to the abdomen (choice D) is not recommended as it can interfere with the natural process of labor.