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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.
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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 alternative could the nurse suggest to someone practicing pica?
- A. Replace laundry starch with salt
- B. Replace ice with frozen fruit juice
- C. Replace soap with cream cheese
- D. Replace soil with uncooked pie crust
Correct Answer: B
Rationale: Replacing ice with frozen fruit juice provides a safer alternative while satisfying the craving for cold substances.
The nurse is assessing a pregnant patient who is at 14 weeks gestation and reports light vaginal bleeding. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and check for protein in the urine.
- B. Call the healthcare provider immediately to assess for miscarriage.
- C. Encourage the patient to rest and wait for symptoms to resolve.
- D. Perform a pelvic exam to check for cervical dilation.
Correct Answer: B
Rationale: The correct answer is B: Call the healthcare provider immediately to assess for miscarriage. The priority action in this scenario is to promptly notify the healthcare provider to assess for potential complications like miscarriage, which could be life-threatening to the patient or fetus. This step ensures timely intervention and appropriate management. Monitoring blood pressure and urine for protein (Choice A) is important but not the immediate priority. Encouraging rest and waiting for symptoms to resolve (Choice C) may delay necessary medical intervention. Performing a pelvic exam (Choice D) could potentially worsen the situation if miscarriage is occurring. Thus, calling the healthcare provider for assessment is the most appropriate and urgent action to take in this situation.
A 37-week gravid client states that she noticed a 'white liquid' leaking from her breasts during a recent shower.
- A. Advise the woman that she may have a galactocele.
- B. Encourage the woman to pump her breasts to stimulate an adequate milk supply.
- C. Assess the liquid because a breast discharge is diagnostic of a mammary infection.
- D. Reassure the mother that this is normal in the third trimester.
Correct Answer: D
Rationale: In the third trimester, colostrum production can cause a white liquid to leak from the breasts. This is a normal physiological response as the body prepares for breastfeeding.
A pregnant patient at 36 weeks gestation reports sudden swelling of the face and hands. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and check for signs of preeclampsia.
- B. Instruct the patient to rest and elevate her feet.
- C. Recommend the patient drink more water to reduce swelling.
- D. Administer diuretics as prescribed to manage fluid retention.
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. At 36 weeks gestation, sudden swelling of the face and hands can indicate preeclampsia, a serious condition characterized by high blood pressure and proteinuria in pregnancy. Monitoring blood pressure and assessing for other signs of preeclampsia, such as headache or vision changes, is crucial for timely diagnosis and intervention to prevent complications for both the mother and baby.
Summary:
B: Instructing the patient to rest and elevate her feet may provide some relief for swelling but does not address the underlying potential issue of preeclampsia.
C: Recommending increased water intake may not be appropriate if the swelling is due to preeclampsia and can worsen the condition.
D: Administering diuretics without proper assessment and diagnosis of preeclampsia can be harmful and is not the initial priority action.