Nokea
A birth plan is being developed by a pregnant couple. Which of the following items should be included in the plan?
- A. The method of infant feeding the mother plans on using.
- B. The name and address of her health care insurance company.
- C. The couple's baby name preferences.
- D. The couple's cell phone numbers.
Correct Answer: A
Rationale: A birth plan typically includes the mother's preferences for labor, delivery, and postpartum care, including infant feeding methods.
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A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. It would be appropriate for the nurse to delegate which of the following actions to the assistant?
- A. Admission assessment on a newly delivered baby.
- B. Patient teaching of a neonatal sponge bath.
- C. Placement of a bag on a baby for urine collection.
- D. Hourly neonatal blood glucose assessments.
Correct Answer: C
Rationale: CNAs can perform tasks such as placing a urine collection bag, which does not require advanced assessment or teaching skills. Admission assessments and blood glucose monitoring require the expertise of an RN.
During a postpartum examination, the nurse notes that a client’s left calf is warm and swollen. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the client’s physician.
- B. Teach the client to massage her leg.
- C. Apply ice packs to the client’s leg.
- D. Encourage the client to ambulate.
Correct Answer: A
Rationale: A warm, swollen calf may indicate deep vein thrombosis (DVT), a serious condition requiring immediate medical attention.
The triage nurse in an obstetric clinic received the following four messages during the lunch hour. Which of the women should the nurse telephone first?
- A. My section incision from last week is leaking a whitish yellow discharge and I have a fever. What should I do?'
- B. I am 39 weeks pregnant with my first baby. I am having contractions about every ten minutes.'
- C. My boyfriend and I had intercourse this morning and our condom broke. What should we do?'
- D. I started my period yesterday. I need some medicine for these terrible menstrual cramps.'
Correct Answer: A
Rationale: A fever and discharge from a surgical incision could indicate an infection, which requires immediate attention. The other situations, while important, are less urgent.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: The best time to schedule the ultrasound immediately is because in early pregnancy, it is crucial to confirm the gestational age, rule out ectopic pregnancy, and assess fetal viability. This allows for accurate dating, identification of potential complications, and timely interventions if needed. Waiting for 2, 4, or 6 weeks could delay necessary care and potentially compromise the well-being of the patient and the fetus. Early detection and management of any issues are essential in ensuring a healthy pregnancy outcome.