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The nurse is providing anticipatory guidance to a woman in her second trimester regarding signs/symptoms that are within normal limits during the latter half of the pregnancy.
- A. During the third trimester I may experience frequent urination.
- B. During the third trimester I may experience heartburn.
- C. During the third trimester I may experience nagging backaches.
- D. During the third trimester I may experience persistent headache.
Correct Answer: A
Rationale: Frequent urination, heartburn, and backaches are common during the third trimester due to the growing uterus putting pressure on the bladder and digestive system, as well as changes in posture. Persistent headaches are not normal and should be reported.
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The nurse is caring for a pregnant patient who has been diagnosed with iron-deficiency anemia. Which of the following should the nurse recommend to improve iron absorption?
- A. Take iron supplements with milk to increase absorption.
- B. Take iron supplements with a vitamin C source, such as orange juice.
- C. Take iron supplements with calcium-rich foods to improve absorption.
- D. Take iron supplements with coffee or tea to aid absorption.
Correct Answer: B
Rationale: The correct answer is B: Take iron supplements with a vitamin C source, such as orange juice. Vitamin C enhances iron absorption by converting non-heme iron (plant-based) into a more absorbable form. This combination increases the bioavailability of iron. Options A, C, and D are incorrect. A: Taking iron supplements with milk can decrease iron absorption due to calcium and casein in milk inhibiting iron absorption. C: Calcium-rich foods can inhibit iron absorption when taken together. D: Coffee and tea contain tannins that can inhibit iron absorption.
A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.)
- A. Ectoderm
- B. Endoderm
- C. Mesoderm
- D. Plastoderm
Correct Answer: A
Rationale: The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm. These layers are responsible for the development of various tissues and organs in the body. Plastoderm and Blastoderm are not part of the primary germ layers.
A pregnant patient at 32 weeks gestation reports swelling in the feet and hands. What should the nurse do first?
- A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
- B. Encourage the patient to elevate her feet and rest for 30 minutes.
- C. Recommend that the patient drink more water and reduce sodium intake.
- D. Assess the patient for signs of a blood clot or deep vein thrombosis.
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 32 weeks gestation, swelling in the feet and hands can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Monitoring blood pressure is crucial as elevated blood pressure is a key indicator of preeclampsia. Assessing for other signs of preeclampsia such as headache, visual disturbances, or upper abdominal pain is important for early detection and management. Prompt intervention is necessary to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because while elevation of feet, rest, hydration, and reducing sodium intake are important in managing mild swelling during pregnancy, in this case, the priority is to rule out preeclampsia which can lead to severe complications if left untreated. Assessing for blood clots or deep vein thrombosis is also important but
The nurse working in an outpatient obstetric office assesses four primigravid clients. Which of the client findings should the nurse highlight for the physician? Select all that apply.
- A. 17 weeks’ gestation; denies feeling fetal movement.
- B. 24 weeks’ gestation; fundal height at the umbilicus.
- C. 27 weeks’ gestation; salivates excessively.
- D. 34 weeks’ gestation; experiences uterine cramping.
Correct Answer: A
Rationale: Denial of fetal movement at 17 weeks and uterine cramping at 34 weeks are concerning findings that should be highlighted for further evaluation. Fundal height at the umbilicus at 24 weeks and excessive salivation at 27 weeks are within normal limits.
A nurse is preparing a laboring person for a cesarean birth. What is the most important action the nurse should take prior to the procedure?
- A. administer a preoperative medication
- B. assist with positioning the person
- C. perform a cesarean section
- D. monitor fetal heart tones
Correct Answer: A
Rationale: The correct answer is A: administer a preoperative medication. This is the most important action because it helps prepare the laboring person for the cesarean birth by ensuring they are adequately medicated for the procedure. Administering preoperative medication can help reduce anxiety, manage pain, and ensure the person is in a suitable condition for surgery.
Summary of other choices:
B: Assisting with positioning the person is important but not the most critical action before a cesarean birth.
C: Performing a cesarean section is not a nursing responsibility and is done by the healthcare provider.
D: Monitoring fetal heart tones is important but not the most crucial action for preparing the laboring person for a cesarean birth.