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The nurse takes the history of a client, G2 P1001, at her first prenatal visit. Which of the following statements would indicate that the client should be referred to a genetic counselor?
- A. My first child has cerebral palsy.
- B. My first child has hypertension.
- C. My first child has asthma.
- D. My first child has cystic fibrosis.
Correct Answer: D
Rationale: Cystic fibrosis is a genetic condition, and a history of it in a previous child would warrant a referral to a genetic counselor. Cerebral palsy, hypertension, and asthma are not typically genetic conditions.
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What response is appropriate regarding sushi consumption during pregnancy?
- A. Fish is healthy
- B. Sushi is too salty
- C. Raw fish is high in mercury
- D. Fish should be cooked
Correct Answer: D
Rationale: Cooking fish destroys harmful bacteria and parasites, reducing the risk of foodborne illnesses during pregnancy.
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.
The nurse is caring for a pregnant patient who is 35 weeks gestation and reports sharp abdominal pain and decreased fetal movement. What is the nurse's priority action?
- A. Encourage the patient to drink water and rest in a comfortable position.
- B. Call the healthcare provider immediately and prepare for further assessment.
- C. Monitor the fetal heart rate and perform a nonstress test.
- D. Ask the patient to lie on her left side and wait for symptoms to resolve.
Correct Answer: B
Rationale: The correct answer is B: Call the healthcare provider immediately and prepare for further assessment. This is the priority action because sharp abdominal pain and decreased fetal movement at 35 weeks gestation could indicate a serious complication such as placental abruption or fetal distress. Calling the healthcare provider promptly allows for timely intervention and assessment to ensure the safety of both the mother and the baby. Encouraging the patient to drink water and rest (choice A) may not address the underlying issue. Monitoring fetal heart rate and performing a nonstress test (choice C) may be important but not as immediate as contacting the healthcare provider. Asking the patient to lie on her left side and wait for symptoms to resolve (choice D) delays necessary medical evaluation and intervention.
A nurse is caring for a postpartum person who is at risk for postpartum hemorrhage. What is the most important nursing action to reduce the risk?
- A. administer oxytocin
- B. administer IV fluids
- C. administer an epidural
- D. perform fundal massage
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate circulating volume, preventing hypovolemia which is a major risk factor for postpartum hemorrhage. This action supports blood pressure and perfusion to reduce the risk of excessive bleeding. Administering oxytocin (A) helps with uterine contraction but does not address the underlying issue of hypovolemia. Administering an epidural (C) is not directly related to preventing postpartum hemorrhage. Fundal massage (D) is important but not the most critical action in reducing the risk of postpartum hemorrhage.
The nurse is assessing the laboratory report of a 40-week gestation client. Which of the following values would the nurse expect to find elevated above prepregnancy levels? Select all that apply.
- A. Glucose.
- B. Fibrinogen.
- C. Hematocrit.
- D. Bilirubin.
Correct Answer: B
Rationale: Fibrinogen levels increase to prevent excessive blood loss during delivery, and white blood cell count rises to protect against infection. Glucose, hematocrit, and bilirubin levels should remain within normal limits.