Nokea
A nurse is caring for a pregnant patient who asks when she should be tested for GBS. What does the nurse tell the patient?
- A. 34–35 weeks
- B. 36–37 weeks
- C. 38–39 weeks
- D. 39–40 weeks
Correct Answer: B
Rationale: The nurse should inform the pregnant patient that Group B Streptococcus (GBS) testing is typically done between 36 and 37 weeks of pregnancy. Testing at this time allows for optimal identification of GBS colonization during childbirth. It is important to test at this stage to determine the presence of GBS in the birth canal, as GBS can be passed to the newborn during delivery, which may lead to serious infections. Testing later in pregnancy increases the likelihood of obtaining accurate results closer to the due date, enabling appropriate management to be implemented to reduce the risk of transmission to the newborn.
You may also like to solve these questions
A nurse is working in the area of labor and birth. Her assignment is to take care of a gravida 1 para 0 woman who presents in early labor at term. Vaginal exam reflects the following: 2 cm, cervix posterior, –1 station, and vertex with membranes intact. The patient asks the nurse if she can break her water so that her labor can go faster. The nurse’s response, based on the ethical principle of nonmaleficence, is which of the following?
- A. Tell the patient that she will have to wait until she has progressed further on the vaginal exam and then she will perform an amniotomy.
- B. Have the patient write down her request and then call the physician for an order to implement the amniotomy.
- C. Instruct the patient that only a physician or certified midwife can perform this procedure.
- D. Give the patient an enema to stimulate labor.
Correct Answer: A
Rationale: The correct response based on the ethical principle of nonmaleficence, which refers to the duty to do no harm, is to tell the patient that she will have to wait until she has progressed further on the vaginal exam and then perform an amniotomy. In this scenario, breaking the patient's water prematurely could introduce risks and potential harm without clear medical necessity. Performing an amniotomy too early could increase the risk of infection or cause umbilical cord prolapse, which can be harmful to both the mother and the baby. Therefore, it is important for the nurse to wait until the patient has progressed further in labor before considering an amniotomy.
The telephone triage nurse receives a call from a patient who is 5 days postoperative total
abdominal hysterectomy. The patient states that her pain is not relieved with the medications and
that she has noticed blood in her urine. The nurse instructs the patient to report immediately to the
emergency department. What does the nurse suspect as the surgical complication?
- A. Possible complication related to the anesthesia
- B. Possible injury to the ureters or bladder
- C. Possible hemorrhage from the internal incision
- D. Possible peritoneal venous thromboembolism
Correct Answer: D
Rationale: In this situation where the patient is 5 days postoperative total abdominal hysterectomy and experiencing pain that is not relieved with medications, the nurse should suspect a possible hemorrhage from the internal incision. Although some pain is expected postoperatively, severe or worsening pain that is not relieved with medications can indicate a complication such as internal bleeding. Immediate medical attention is needed to assess and manage any potential hemorrhage to prevent further complications or adverse outcomes. Other signs of internal bleeding may include symptoms such as increasing abdominal distention, tachycardia, hypotension, and signs of shock.
What assessment finding suggests that a patient may have fibrocystic breast changes?
- A. green-tinged nipple discharge
- B. ongoing breast pain
- C. firm, ropy feel of the breast tissue under the skin
- D. peau d’orange appearance of the skin
Correct Answer: C
Rationale: Fibrocystic breast changes typically present with breast pain and a cyclic pattern of nodularity and/or lumps in the breast tissue. The characteristic assessment finding that suggests fibrocystic breast changes is the firm, ropy feel of the breast tissue under the skin. This texture is due to the presence of fibrous tissue and cysts within the breast, which can be felt during the physical examination. While nipple discharge and skin changes like peau d’orange can be associated with different breast conditions, the firm and ropy feel of the breast tissue is more specific to fibrocystic changes.
A patient arrives to the clinic 2 hours late for her prenatal appointment. This is the third time she has been late. What is the nurse’s best action in response to this patient’s tardiness?
- A. Ask the patient if she has a way to tell the time.
- B. Ask the patient if she is deliberately being late for her appointments.
- C. Determine if the patient wants this baby and if this is her way of acting out.
- D. Determine if the patient arrives after the start time for other types of appointments.
Correct Answer: C
Rationale: The nurse's best action in response to the patient's tardiness is to determine if the patient wants this baby and if this is her way of acting out. Tardiness to prenatal appointments can sometimes indicate underlying issues such as ambivalence towards the pregnancy or emotional distress. By addressing the patient's motivation for being consistently late, the nurse can better understand and support her needs. This approach allows for a more patient-centered and compassionate response, aiming to address any possible concerns or challenges the patient may be facing.
The nurse is providing care to a 72-year-old female patient. While providing care, the nurse instructs the patient to slowly rise from a sitting or prone position. What is the pathophysiological reason for this instruction?
- A. The patient is at higher risk for fractures due to postmenopausal osteoporosis.
- B. The patient is at higher risk for hypotension due to decreased baroreceptor sensitivity.
- C. The patient is at higher risk for falls due to decreased muscle strength and balance
- D. The patient is at higher risk for adverse drug reactions due to decreased hepatic function
Correct Answer: B
Rationale: As people age, their baroreceptor sensitivity decreases, making them more prone to orthostatic hypotension, especially when changing positions quickly. Orthostatic hypotension is a significant concern in the elderly population as it can lead to falls and injuries. By instructing the patient to rise slowly from a sitting or prone position, the nurse is helping to prevent a rapid drop in blood pressure that can occur with sudden position changes. This precaution is particularly important in elderly patients to minimize the risk of falls and subsequent injuries.