Nokea
A nurse working in a community hospital’s emergency department provides care to a patient having chest pain. Which level of care is the nurse providing?
- A. Continuing care
- B. Restorative care
- C. Preventive care
- D. Tertiary care
Correct Answer: D
Rationale: Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care.
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What does a birth plan help the parents accomplish?
- A. Avoidance of an episiotomy
- B. Determining the outcome of the birth
- C. Assuming complete control of the situation
- D. Taking an active part in planning the birth experience
Correct Answer: D
Rationale: The correct answer is D because a birth plan allows parents to actively participate in planning their birth experience by outlining their preferences and wishes. It helps them communicate their desires to healthcare providers and ensures their preferences are considered during labor and delivery. Choice A is incorrect as avoiding an episiotomy is a specific medical procedure, not the primary purpose of a birth plan. Choice B is incorrect as determining the outcome of birth is not within the control of parents. Choice C is incorrect as assuming complete control of the situation may not be realistic or safe during childbirth.
A 36-week-gestation client is having an amniocentesis. For which of the following reasons is the test likely being conducted?
- A. Genetic evaluation.
- B. Assessment of intrauterine growth restriction.
- C. Assessment of fetal lung maturation.
- D. Hormonal studies.
Correct Answer: C
Rationale: Amniocentesis at 36 weeks is often performed to assess fetal lung maturity before delivery.
In a prenatal education class, the nurse is reviewing the importance of using relaxation techniques during labor. Which patient statement will the nurse need to correct?
- A. We will practice relaxation techniques only in a quiet setting so I can focus.'
- B. Relaxation is important during labor because it will help me conserve my energy.'
- C. If I relax in between contractions, my baby will get more oxygen during labor.'
- D. My partner and I will practice relaxation throughout the remainder of my pregnancy.'
Correct Answer: A
Rationale: The correct answer is A because relaxation techniques should be practiced not just in quiet settings but also during labor, regardless of the environment. This is important to help manage pain and promote a smoother labor process. Choice B is correct as relaxation can indeed help conserve energy. Choice C is incorrect as oxygenation to the baby is not directly related to the mother's relaxation between contractions. Choice D is also incorrect as relaxation techniques should be practiced specifically during labor as well, not just throughout the pregnancy.
A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.
The nurse is caring for a baby whose blood type is A+ (positive) and direct Coombs’ test is + (positive), and whose mother’s blood type is O+ (positive). Which of the following nursing diagnoses is appropriate for this baby?
- A. Risk for injury to the central nervous system.
- B. Risk for fluid volume deficit.
- C. Risk for interrupted family processes.
- D. Risk for impaired parent-infant attachment.
Correct Answer: A
Rationale: A positive Coombs’ test indicates hemolytic disease of the newborn, which can lead to bilirubin buildup and potential central nervous system damage.