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A woman, contracting every 3 min 60 seconds, suddenly develops an amniotic fluid embolism. Which of the following signs/symptoms would the nurse observe?
- A. Sudden gush of fluid from the vagina.
- B. Intense and unrelenting uterine pain.
- C. Precipitous dilation and expulsion of the fetus.
- D. Chest pain with dyspnea and cyanosis.
Correct Answer: D
Rationale: Amniotic fluid embolism can cause sudden cardiovascular collapse, including chest pain, dyspnea, and cyanosis.
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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.
The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
- A. Repeat the test in 1 week so that results can be trended based on this baseline result.
- B. Contact the health care provider to discuss birth options for the patient.
- C. Send the patient out for a meal and repeat the test to confirm that the results are valid.
- D. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.
Correct Answer: B
Rationale: The correct answer is B because a positive contraction stress test (CST) indicates potential fetal distress, requiring immediate medical attention. Contacting the health care provider is necessary to discuss birth options for the patient, such as potential induction or cesarean section to prevent harm to the fetus.
A is incorrect because waiting another week could pose risks to the fetus if distress is already present. C is incorrect as sending the patient out for a meal and repeating the test is not a valid or necessary intervention. D is incorrect as a fetal kick count assessment does not address the immediate concerns raised by a positive CST result.
When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: The correct answer is C: 10 weeks. CVS is typically performed between 10-12 weeks of gestation. At this time, there is enough fetal tissue for sampling without significant risk to the pregnancy. Performing CVS earlier (options A, B) may result in insufficient tissue for accurate testing, while performing it later (option D) may increase the risk of procedure-related complications. Option C provides the optimal balance between ensuring accurate results and minimizing potential risks to the pregnancy.
The nurse receives a phone call from a pregnant patient who states she has not felt the baby move. Identify the first question for the nurse to ask the patient.
- A. Have you experienced any recent vaginal bleeding?
- B. Have you experienced any recent vaginal discharge?
- C. How many weeks pregnant are you?
- D. When was the last time you felt the baby move?
Correct Answer: D
Rationale: The correct first question for the nurse to ask the patient is D: When was the last time you felt the baby move? This question is crucial because it helps assess the fetal well-being and can indicate any potential issues with the baby's health or development. It allows the nurse to determine if there has been a recent decrease in fetal movements, which could be a sign of distress. Asking about vaginal bleeding or discharge (choices A and B) may not provide immediate insight into the baby's well-being. Question C is relevant but not as urgent as knowing when the baby was last felt moving.
A nurse is completing a minimum data set. Which area is the nurse working?
- A. Nursing center
- B. Psychiatric facility
- C. Rehabilitation center
- D. Adult day care center
Correct Answer: A
Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.