Nokea
A client enters the prenatal clinic. She states that she missed her period yesterday and used a home pregnancy test this morning. She states that the results were negative, but 'I still think I am pregnant.' Which of the following statements would be appropriate for the nurse to make at this time?
- A. Your period is probably just irregular.
- B. We could do a blood test to check.
- C. Home pregnancy test results are very accurate.
- D. My recommendation would be to repeat the test in one week.
Correct Answer: B
Rationale: A blood test is more accurate than a home pregnancy test, especially early in pregnancy. Repeating the test in a week is also an option, but a blood test provides more immediate and reliable results.
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During a preconception counseling session, the nurse encourages a couple to prepare a birth plan.
- A. Promote communication between the couple and health care professionals.
- B. Enable the couple to learn about the types of pain medicine used in labor.
- C. Provide the couple with a list of items that they should take to the hospital for the labor and delivery.
- D. Give the high-risk couple a sense of control over the likelihood of having a surgical delivery.
Correct Answer: A
Rationale: A birth plan fosters open communication between the couple and healthcare providers, ensuring that expectations and preferences are understood.
A patient at 36 weeks gestation is undergoing a nonstress test (NST). The nurse observes the fetal heart rate baseline at 135 bpm and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for 20-25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: An NST is reactive and reassuring when two or more accelerations occur within 20 minutes, indicating fetal well-being.
A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most important intervention to prevent DVT?
- A. administer anticoagulants
- B. administer IV fluids
- C. perform leg exercises
- D. ensure early ambulation
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate hydration which prevents blood from becoming too thick and reduces the risk of clot formation. Adequate hydration also promotes blood circulation, decreasing the risk of DVT. Administering anticoagulants (choice A) is important in managing DVT but is not the most important preventive intervention. Performing leg exercises (choice C) and ensuring early ambulation (choice D) are also beneficial in preventing DVT, but maintaining hydration with IV fluids is the most crucial intervention as it directly addresses the primary factor contributing to DVT formation.
A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
- A. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results.
- B. Maintain NPO status prior to testing.
- C. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
- D. Have an infusion pump prepared with oxytocin per protocol for evaluation.
Correct Answer: C
Rationale: The patient should be positioned comfortably, and the tocotransducer should be adjusted to obtain an accurate fetal heart rate reading.