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Which of the following vital sign changes should the nurse highlight for a pregnant woman’s obstetrician?
- A. Prepregnancy blood pressure (BP) 100/60 and third trimester BP 140/90.
- B. Prepregnancy respiratory rate (RR) 16 rpm and third trimester RR 22 rpm.
- C. Prepregnancy heart rate (HR) 76 bpm and third trimester HR 88 bpm.
- D. Prepregnancy temperature (T) 98.6°F and third trimester T 99.2°F.
Correct Answer: A
Rationale: A significant increase in blood pressure, particularly to 140/90, could indicate preeclampsia and should be highlighted for further evaluation. The other changes are within normal limits for pregnancy.
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A pregnant patient is at 25 weeks gestation and is concerned about her risk of preterm labor. Which of the following symptoms should the nurse educate the patient to report immediately?
- A. Mild back pain and cramping
- B. Increased vaginal discharge
- C. Painful, regular contractions
- D. Feeling of pelvic pressure after physical activity
Correct Answer: C
Rationale: The correct answer is C: Painful, regular contractions. At 25 weeks gestation, experiencing painful, regular contractions could indicate preterm labor, which requires immediate medical attention to prevent premature birth. Mild back pain and cramping (choice A) are common in pregnancy and may not necessarily indicate preterm labor. Increased vaginal discharge (choice B) is also common in pregnancy and not typically a sign of preterm labor. Feeling of pelvic pressure after physical activity (choice D) is common due to the growing uterus and ligament stretching, but it is not a definitive sign of preterm labor unless accompanied by other symptoms like contractions.
A client enters the prenatal clinic. She states that she believes she is pregnant. Which of the following hormone elevations will indicate a high probability that the client is pregnant?
- A. Chorionic gonadotropin.
- B. Oxytocin.
- C. Prolactin.
- D. Luteinizing hormone.
Correct Answer: A
Rationale: Chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests and is a definitive indicator of pregnancy. Oxytocin, prolactin, and luteinizing hormone are not specific to pregnancy.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks’ gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: In diabetic pregnancies, an L/S ratio of 2:1 may not reliably indicate lung maturity due to delayed surfactant production.
A pregnant patient is at 32 weeks gestation and reports swelling of the feet and legs. What is the most appropriate recommendation for the nurse to make?
- A. Limit fluid intake to reduce swelling.
- B. Elevate the legs and avoid prolonged standing.
- C. Apply compression stockings to improve circulation.
- D. Rest in bed with the feet elevated at all times.
Correct Answer: B
Rationale: The correct answer is B. Elevating the legs and avoiding prolonged standing is the most appropriate recommendation for a pregnant patient experiencing swelling at 32 weeks gestation. Elevating the legs helps to reduce swelling by aiding in venous return and reducing fluid accumulation in the lower extremities. Prolonged standing can worsen swelling due to increased pressure on the veins. Limiting fluid intake (choice A) may lead to dehydration and is not recommended during pregnancy. Applying compression stockings (choice C) may help improve circulation but may not address the underlying cause of swelling. Resting in bed with feet elevated at all times (choice D) is excessive and may not be practical for the patient.
A nurse is preparing a laboring person for an epidural. What is the most important intervention before the procedure?
- A. ensure informed consent
- B. assist with proper positioning
- C. check for allergies to anesthesia
- D. educate on wound care
Correct Answer: C
Rationale: The correct answer is C: check for allergies to anesthesia. Before administering an epidural, it is crucial to check for any allergies to anesthesia to prevent potential allergic reactions. This step ensures the safety and well-being of the laboring person. Informed consent (choice A) is important but not the most critical step before an epidural. Proper positioning (choice B) is essential during the procedure but not the top priority before it. Educating on wound care (choice D) is not directly relevant to preparing for an epidural.