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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.
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A 39-week-gestation client is admitted to the labor and delivery unit for a scheduled cesarean delivery. The nurse should inform the surgeon regarding which of the following admission laboratory findings?
- A. Potassium 4.9 mEq/L.
- B. Sodium 136 mEq/L.
- C. Platelet count 75,000 cells/mm3.
- D. White blood cell count 15,000 cells/mm3.
Correct Answer: C
Rationale: A platelet count of 75,000 cells/mm3 is low and could increase the risk of bleeding during surgery. The surgeon should be informed to take appropriate precautions.
A nurse has just inserted an orogastric gavage tube into a preterm baby. When would the nurse determine that the tube is in the proper location?
- A. When gastric aspirate is removed from the tube.
- B. When the baby suckles on the tubing.
- C. When respirations are unlabored during tube insertion.
- D. When the tubing can be inserted no farther.
Correct Answer: A
Rationale: The presence of gastric aspirate confirms that the tube is in the stomach, which is the proper location for feeding.
The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
- A. During labor, when she can no longer talk through contractions
- B. During the first stage of labor, when the contractions are 3 to 4 minutes apart
- C. Between contractions, during the transitional phase of the first stage of labor
- D. Between her efforts to push to facilitate relaxation between contractions
Correct Answer: A
Rationale: The correct answer is A: During labor, when she can no longer talk through contractions. This is the best time to encourage slow, deep chest breathing as it helps the laboring patient stay calm, focused, and manage pain effectively during the intense active phase of labor. When a woman reaches the point where she can no longer talk through contractions, it indicates that she is in the active phase of labor and may benefit from slow, deep breathing to help cope with the intensity of contractions.
Explanation for why other choices are incorrect:
B: During the first stage of labor, when the contractions are 3 to 4 minutes apart - Contractions being 3 to 4 minutes apart may not necessarily indicate the active phase of labor requiring slow, deep breathing.
C: Between contractions, during the transitional phase of the first stage of labor - Transitional phase contractions are typically intense and close together, making it less ideal for relaxation breathing between contractions.
D: Between her efforts
A pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient's plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: The correct answer is B: Refer to the physician for additional testing. When a triple-screen test is positive in a pregnant patient, it indicates an increased risk of certain conditions such as neural tube defects or chromosomal abnormalities. Therefore, the appropriate course of action is to refer the patient to a physician for further diagnostic testing, such as amniocentesis or ultrasound, to confirm or rule out these conditions.
Choice A is incorrect because a positive result on a triple-screen test does not indicate that results are normal; it suggests the need for further investigation. Choice C is incorrect because validating the results with the lab facility does not address the need for additional diagnostic testing. Choice D is incorrect because waiting 2 weeks to repeat the test and returning for a regular prenatal visit may delay necessary interventions or treatment for the patient.
A woman, who is in pain from a diagnosis of mastitis, has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following?
- A. Mammary rupture.
- B. Postpartum psychosis.
- C. Supernumerary nipples.
- D. Breast abscess.
Correct Answer: D
Rationale: Abrupt weaning can lead to milk stasis, increasing the risk of a breast abscess due to bacterial infection.