Nokea
A nurse is caring for a client who is receiving prenatal care and is at her 24- week appointment. Which of the following laboratory tests should the nurse plans to conduct?
- A. Group B strep culture
- B. 1-hr glucose tolerance test
- C. Rubella titer
- D. Blood type and Rh
Correct Answer: D
Rationale: At the 24-week prenatal appointment, it is essential to conduct the blood type and Rh test for the pregnant client. Determining the mother's blood type (A, B, AB, O) and Rh factor (positive or negative) is crucial as it helps identify if the mother is Rh-negative and at risk for Rh incompatibility with her baby. This information is vital for appropriate management to prevent potential complications such as hemolytic disease of the newborn. Conducting the blood type and Rh test at this stage allows healthcare providers to take necessary precautions to protect both the mother and the fetus.
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A family member stands at the nurse station and requests help for their partner. What response should the nurse give to the family member?
- A. Are you the husband?
- B. Who is your wife?
- C. What can I do to help you and your partner?
- D. Are you part of the trans couple in room 214?
Correct Answer: C
Rationale: A neutral and inclusive response ensures the family member feels respected and supported.
A patient asks the nurse about using the basal body temperature method as contraception. What statement made by the patient indicates that the patient needs further teaching?
- A. “I need to take my temperature before I even sit up in bed.â€
- B. “A rise of 0.4° F above my baseline temperatures for 3 days indicates it is safe to have condomless sex.â€
- C. “I need to use a special thermometer to take my basal body temperature.â€
- D. “I know I am about to ovulate when my temperature rises at least 0.4° F.â€
Correct Answer: B
Rationale: Option B is the statement made by the patient that indicates the need for further teaching. In the basal body temperature method of contraception, a sustained temperature rise typically indicates ovulation has already occurred, making it unsafe to have condomless sex. It is the drop in temperature just before ovulation that is used to predict a fertile window. Therefore, a rise in temperature would not indicate that it is safe to have condomless sex. The patient should be educated that the temperature shift indicates the end of the fertile window and that it is safest to avoid unprotected sex during the fertile window.
What does the nursing process describe?
- A. what nurses do
- B. how nurses think
- C. where nurses provide care
- D. who nurses care for
Correct Answer: B
Rationale: The nursing process describes how nurses think and approach patient care. It is a systematic problem-solving approach that nurses use to provide individualized patient care. The nursing process consists of five main steps: assessment, diagnosis, planning, implementation, and evaluation. Through this process, nurses gather information, identify patient problems, set goals, implement interventions, and evaluate outcomes. By following the nursing process, nurses can deliver holistic and effective care to their patients.
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
- A. Administer nitric oxide inhalation therapy to the newborn
- B. Insert an orogastric decompression tube with low wall suction.
- C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
- D. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.
Correct Answer: D
Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.