Nokea
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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Which finding indicates the best quality improvement process?
- A. Staff identifies the wait time in the emergency department is too long.
- B. Administration identifies the design of the facility’s lobby increases patient stress.
- C. Director of the hospital identifies the payment schedule does not pay enough for overtime.
- D. Health care providers identify the inconsistencies of some of the facility’s policy and procedures.
Correct Answer: A
Rationale: The quality improvement process begins at the staff level, where problems are defined by the staff. It is not identified by administration, the hospital director, or health care providers.
In which type of health care facility does the nurse want to work if applying for a position with a home care organization that specializes in spinal cord injury?
- A. Secondary acute
- B. Continuing
- C. Restorative
- D. Tertiary
Correct Answer: C
Rationale: Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability.
A woman and man have the following genotypes for an autosomal dominant disease: Aa and Aa. If asked, which of the following should the nurse say is the probability of their child having the disease?
- A. 25% probability.
- B. 50% probability.
- C. 75% probability.
- D. 100% probability.
Correct Answer: C
Rationale: The probability of their child having the disease is 75% because both parents are carriers (Aa). The possible genotypes for the child are AA, Aa, aA, and aa. Only the aa genotype would not result in the disease, giving a 75% chance of the child having the disease.
The nurse is admitting a client, who reports, 'My water broke yesterday, and I haven't felt my baby move any today.' She is 38 weeks with a history of gestational diabetes. Which assessment data is of most concern to the nurse on admission?
- A. Maternal vital signs: T 100.2, HR 104, RR 20, BP 136/82
- B. Pain score 6/10
- C. Minimal variability and variable decelerations
- D. 5 cm/80% effaced/0 station
Correct Answer: C
Rationale: The correct answer is C because minimal variability and variable decelerations on fetal heart monitoring indicate fetal distress, which is a critical concern. Minimal variability suggests the baby's nervous system is compromised, and decelerations can indicate umbilical cord compression or placental insufficiency, possibly leading to fetal hypoxia. This situation requires immediate intervention to prevent potential harm to the baby.
Choice A is incorrect as the vital signs are slightly elevated but not as concerning as fetal distress. Choice B is incorrect as pain score is subjective and not as critical as fetal well-being. Choice D is incorrect as cervical dilation/effacement/station is important for labor progress but not as concerning as fetal distress in this scenario.
The nurse is performing Leopold's maneuvers on a pregnant patient at 36 weeks of gestation and determines the fetal lie is longitudinal, palpates the fetal legs in the top of the uterus, and palpates the fetal head above the symphysis pubis. Which fetal presentation does the nurse document in the EHR?
- A. cephalic
- B. compound
- C. transverse
- D. breech
Correct Answer: D
Rationale: The correct answer is D: breech. At 36 weeks of gestation, if the nurse palpates the fetal head above the symphysis pubis and the fetal legs are at the top of the uterus, it indicates a breech presentation where the baby's buttocks or feet are positioned to be delivered first. In a breech presentation, the fetal head is not engaged in the pelvis and is palpable above the symphysis pubis. The longitudinal lie with the fetal legs on top further supports the breech presentation.
Summary:
A: Cephalic presentation would have the fetal head engaged in the pelvis.
B: Compound presentation involves an additional body part alongside the presenting part.
C: Transverse lie would have the baby positioned horizontally across the uterus.
D: Breech presentation aligns with the given scenario of palpating fetal legs on top and head above the symphysis pubis.