Nokea
Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client?
- A. Anemia.
- B. Thrombocytopenia.
- C. Polycythemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: Anemia is relatively common in pregnancy due to increased blood volume and iron demands. Polycythemia, thrombocytopenia, and hyperbilirubinemia are not typical findings.
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A pregnant patient at 28 weeks gestation reports lightheadedness and fainting when standing up. What is the most likely cause of these symptoms?
- A. Dehydration and electrolyte imbalance
- B. Increased blood volume and decreased blood pressure
- C. Iron-deficiency anemia
- D. Hyperglycemia from gestational diabetes
Correct Answer: B
Rationale: The correct answer is B: Increased blood volume and decreased blood pressure. At 28 weeks gestation, the pregnant patient's blood volume significantly increases to support the developing fetus, causing a relative decrease in blood pressure when standing up (orthostatic hypotension). This can lead to lightheadedness and fainting. Dehydration and electrolyte imbalance (choice A) can contribute to these symptoms but are less likely in a pregnant patient. Iron-deficiency anemia (choice C) can cause similar symptoms but is less common at 28 weeks gestation. Hyperglycemia from gestational diabetes (choice D) typically presents with other symptoms like excessive thirst and urination, rather than lightheadedness and fainting.
A nurse is providing prenatal education to a patient who is at 20 weeks gestation. Which of the following statements indicates that the teaching has been effective?
- A. I will avoid exercising during pregnancy to protect my baby.
- B. I will drink plenty of water and rest when I feel tired.
- C. I will eat for two to ensure my baby gets enough nutrition.
- D. I will attend all of my prenatal visits and follow my doctor's advice.
Correct Answer: D
Rationale: The correct answer is D because attending all prenatal visits and following the doctor's advice is crucial for monitoring the health of both the mother and the baby. It ensures early detection of any potential issues and proper management throughout the pregnancy. This statement shows the patient's commitment to their prenatal care, which is essential for a healthy pregnancy outcome.
Explanation for why other choices are incorrect:
A: Avoiding exercise completely is not recommended during pregnancy, as moderate exercise is beneficial for both the mother and the baby.
B: While staying hydrated and resting when tired are important, they do not solely indicate effective prenatal education.
C: Eating for two is a common misconception; the focus should be on a balanced diet rather than overeating.
A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?
- A. apply warm compresses
- B. apply cold compresses
- C. provide distraction techniques
- D. apply lanolin cream
Correct Answer: B
Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.
A nurse is caring for a laboring person who is in the first stage of labor. What is the most important assessment to perform during this stage?
- A. assess fetal heart rate
- B. monitor contractions
- C. check blood pressure
- D. assist with breathing exercises
Correct Answer: A
Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring the fetal heart rate is crucial as it indicates the well-being of the baby. Changes in fetal heart rate can signal distress and prompt intervention. Monitoring contractions is important but assessing fetal well-being takes precedence. Checking blood pressure is important but not the most critical in this stage. Assisting with breathing exercises can help manage pain, but assessing fetal heart rate is more crucial for ensuring the baby's safety.
The nurse is caring for a pregnant patient who is 38 weeks gestation and has a history of gestational hypertension. Which of the following symptoms would indicate the need for immediate medical attention?
- A. Mild swelling in the feet and ankles
- B. Headaches and blurred vision
- C. Occasional lower back pain
- D. Fatigue and slight nausea
Correct Answer: B
Rationale: The correct answer is B: Headaches and blurred vision. These symptoms can indicate a serious condition called preeclampsia, which can be life-threatening for both the mother and the baby. Headaches and blurred vision are signs of increased blood pressure and potential organ damage. Immediate medical attention is crucial to monitor and manage preeclampsia.
A: Mild swelling in the feet and ankles is common in pregnancy and not necessarily indicative of a serious issue.
C: Occasional lower back pain is also common in pregnancy and may not require immediate medical attention.
D: Fatigue and slight nausea are common pregnancy symptoms and do not typically indicate a need for immediate medical attention.