Nokea
When assessing the psychological adjustment of an 8-week gravida, which of the following would the nurse expect to see signs of?
- A. Ambivalence.
- B. Depression.
- C. Anxiety.
- D. Ecstasy.
Correct Answer: A
Rationale: Ambivalence is a common psychological response in early pregnancy as the client adjusts to the idea of being pregnant. Depression, anxiety, and ecstasy are less common at this stage.
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A patient in labor is undergoing an epidural block and develops hypotension. What should the nurse do first?
- A. Increase intravenous fluids
- B. Place the patient in a Trendelenburg position
- C. Administer oxygen via face mask
- D. Notify the physician immediately
Correct Answer: A
Rationale: The correct first action is to increase intravenous fluids (Choice A). This will help improve the patient's blood volume and subsequently increase blood pressure. Trendelenburg position (Choice B) is not recommended due to potential complications. Administering oxygen (Choice C) may be helpful but doesn't directly address the hypotension. Notifying the physician (Choice D) is important but addressing hypotension promptly is the priority. Increasing fluids helps address the underlying cause of hypotension in this scenario.
Which clinical conditions are associated with increased levels of alpha-fetoprotein (AFP)? (Select all that apply.)
- A. Down syndrome
- B. Molar pregnancy
- C. Twin gestation
- D. Incorrect gestational age assessment of a normal fetus—estimation is earlier in the pregnancy
Correct Answer: C
Rationale: Elevated AFP levels are seen in multiple gestations, miscalculated gestational age, and threatened abortion.
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 patient who is 40 weeks pregnant presents to the labor and delivery unit with decreased fetal movement. What is the first step in management?
- A. Perform a nonstress test (NST)
- B. Administer a corticosteroid injection
- C. Monitor fetal heart rate
- D. Monitor the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Perform a nonstress test (NST). This is the first step in assessing fetal well-being when a patient presents with decreased fetal movement at 40 weeks gestation. The NST evaluates fetal heart rate in response to fetal movement, providing immediate information on fetal well-being. Administering a corticosteroid injection (B) would not be indicated at this point as it is not the first-line management for decreased fetal movement. Monitoring fetal heart rate (C and D) is important, but the NST provides more comprehensive information on fetal well-being.
A nurse is caring for a pregnant patient who is at 22 weeks gestation and reports experiencing vaginal bleeding. What is the nurse's priority action?
- A. Encourage the patient to rest and avoid strenuous activity.
- B. Monitor the fetal heart rate and assess for any signs of preterm labor.
- C. Assess the bleeding and notify the healthcare provider immediately.
- D. Instruct the patient to use a sanitary pad to monitor for changes in bleeding.
Correct Answer: C
Rationale: The correct answer is C: Assess the bleeding and notify the healthcare provider immediately. This is the priority action because vaginal bleeding during pregnancy can indicate serious complications such as placental abruption or preterm labor. By assessing the bleeding, the nurse can determine the severity and nature of the bleeding to provide crucial information to the healthcare provider for prompt intervention. Notifying the healthcare provider immediately ensures timely assessment and appropriate management to protect the health and well-being of both the mother and fetus. Encouraging rest (choice A) may be appropriate, but assessing the bleeding and notifying the healthcare provider take precedence. Monitoring fetal heart rate (choice B) is important but secondary to assessing the bleeding. Instructing the patient to use a sanitary pad (choice D) is not sufficient to address the potential underlying causes of vaginal bleeding.