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What is the nurse's initial action?
- A. Assess food intake.
- B. Weigh the patient again.
- C. Take the blood pressure.
- D. Notify the physician.
Correct Answer: C
Rationale: A 10-pound weight gain in 2 weeks may indicate pre-eclampsia, so blood pressure should be assessed first.
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How would the nurse document the patient's obstetric history using the TPALM system?
- A. Gravida 2, para 20120
- B. Gravida 3, para 10011
- C. Gravida 3, para 10110
- D. Gravida 2, para 11110
Correct Answer: C
Rationale: The TPALM system records gravida (total pregnancies) and para (outcomes). The patient has 3 pregnancies (current, one son, one abortion), with 1 term birth, 0 preterm, 1 abortion, 1 living child, 0 multiple births.
What does the nurse explain as the most likely cause of this symptom?
- A. Supine hypotension syndrome
- B. Gestational diabetes
- C. Pregnancy-induced hypertension
- D. Malnutrition
Correct Answer: A
Rationale: Supine hypotension syndrome occurs when lying on the back, causing dizziness due to aortocaval compression.
What is folic acid thought to decrease the incidence of in fetal development?
- A. Structural heart defects
- B. Craniofacial deformities
- C. Limb deformities
- D. Neural tube defects
Correct Answer: D
Rationale: Folic acid reduces the incidence of neural tube defects such as spina bifida and anencephaly.
What will the nurse advise the woman regarding recommended weight gain during pregnancy?
- A. 10 to 20 pounds
- B. 15 to 25 pounds
- C. 25 to 35 pounds
- D. 28 to 40 pounds
Correct Answer: C
Rationale: The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds.
What would the nurse explain as the cause of Chadwick's sign?
- A. Enlargement of the uterus
- B. Progesterone action on the breasts
- C. Increasing activity of the fetus
- D. Vascular congestion in the pelvic area
Correct Answer: D
Rationale: Chadwick's sign is caused by increased vascular congestion in the cervical and vaginal area.