Nokea
The nurse is providing prenatal education to a pregnant patient about the signs of labor. Which of the following symptoms should the nurse instruct the patient to report immediately?
- A. Feeling pressure in the lower abdomen
- B. A bloody show or the loss of the mucous plug
- C. Regular contractions every 5 minutes for 1 hour
- D. A sudden increase in fetal movements
Correct Answer: C
Rationale: The correct answer is C: Regular contractions every 5 minutes for 1 hour. This is a sign of active labor and indicates that the patient should seek immediate medical attention. Contractions at this frequency and duration suggest that labor is progressing and the patient should go to the hospital. Choices A, B, and D are not indicative of active labor and do not require immediate medical attention. Feeling pressure in the lower abdomen may be a normal part of pregnancy. A bloody show or loss of the mucous plug can be early signs of labor but do not require immediate attention unless accompanied by other symptoms. A sudden increase in fetal movements is generally considered a positive sign of fetal well-being.
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A patient in labor is undergoing an epidural block and is given intravenous fluid. What is the purpose of this?
- A. To treat hypotension that results from hemorrhage
- B. To increase urine output
- C. To treat insensible fluid losses
- D. To treat hypotension that results from sympathetic blockade
Correct Answer: D
Rationale: The correct answer is D: To treat hypotension that results from sympathetic blockade. When an epidural block is administered during labor, sympathetic blockade can lead to a drop in blood pressure. By providing intravenous fluid, the goal is to increase preload and maintain blood pressure to counteract the hypotension caused by sympathetic blockade.
A: Treating hypotension from hemorrhage is not the primary purpose in this scenario.
B: Increasing urine output is not the main goal of giving intravenous fluid during an epidural block.
C: Treating insensible fluid losses is not the immediate concern when a patient is experiencing hypotension from sympathetic blockade.
A pregnant patient is at 34 weeks gestation and reports sudden sharp abdominal pain and difficulty breathing. What is the nurse's priority action?
- A. Encourage the patient to lie down and monitor the symptoms.
- B. Administer pain medication and schedule an ultrasound.
- C. Call the healthcare provider immediately and prepare for possible preterm labor.
- D. Assess the fetal heart rate and monitor for contractions.
Correct Answer: C
Rationale: The correct answer is C - Call the healthcare provider immediately and prepare for possible preterm labor. At 34 weeks gestation, sudden sharp abdominal pain and difficulty breathing could indicate a serious complication such as placental abruption or pulmonary embolism. Calling the healthcare provider ensures prompt assessment and appropriate intervention to prevent harm to the mother and baby. Encouraging the patient to lie down may delay necessary intervention. Administering pain medication before determining the cause of pain could mask important symptoms. Assessing the fetal heart rate and monitoring for contractions are important but secondary actions to calling the healthcare provider in this urgent situation.
A pregnant patient at 32 weeks gestation is concerned about gestational diabetes. What is the nurse's priority intervention?
- A. Encourage the patient to eat smaller, more frequent meals and monitor blood glucose levels.
- B. Administer insulin as prescribed to control blood glucose levels.
- C. Recommend a high-protein, low-carbohydrate diet to prevent blood sugar spikes.
- D. Instruct the patient to limit fluid intake to reduce blood sugar fluctuations.
Correct Answer: A
Rationale: The correct answer is A because it addresses the immediate concern of managing blood glucose levels in a pregnant patient with gestational diabetes. Encouraging smaller, more frequent meals helps stabilize blood sugar levels and prevent spikes. Monitoring blood glucose levels is crucial for timely interventions. Administering insulin (B) may be necessary but not the priority. A high-protein, low-carb diet (C) is not typically recommended for gestational diabetes. Limiting fluid intake (D) is not appropriate as hydration is important during pregnancy. In summary, choice A is the priority as it directly addresses the patient's concern and promotes optimal blood sugar control during pregnancy.
What is the priority intervention for a laboring person with a suspected uterine rupture?
- A. prepare for an emergency cesarean section
- B. perform uterine massage
- C. apply pressure to the abdomen
- D. monitor the fetal heart rate continuously
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation.
Incorrect choices:
A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial.
C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications.
D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. What sample will be collected for the initial screening process?
- A. Urine
- B. Blood
- C. Saliva
- D. Amniotic fluid
Correct Answer: B
Rationale: AFP screening is done using a blood sample, which is less invasive than an amniocentesis.