Nokea
A woman is admitted to the labor and delivery unit with active tuberculosis. She has not been under a physician's care and is not on medication. Which of the following actions should the nursery nurse perform when the neonate is delivered?
- A. Isolate the baby from the other babies in a special care nursery.
- B. Keep the baby in the regular care nursery but separated from the mother.
- C. Isolate the baby with the mother in the mother's room.
- D. Obtain an order from the doctor for antituberculosis medications for the baby.
Correct Answer: A
Rationale: The baby should be isolated to prevent the spread of tuberculosis to other neonates. The mother should also be treated, but the immediate concern is preventing transmission to others.
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The nurse is caring for a client, 37 weeks' gestation, who was just told that she is group B strep + (positive). The client states, 'How could that happen? I only have sex with my husband. Will my baby be OK?' Based on this information, which of the following should the nurse communicate to the client?
- A. The client's partner must have acquired the bacteria during a sexual encounter.
- B. The bacteria do not injure babies, but they could cause the client to have a bad sore throat.
- C. The client is high risk for developing pelvic inflammatory disease from the bacteria.
- D. Antibiotics will be administered during labor to prevent vertical transmission of the bacteria.
Correct Answer: D
Rationale: Group B strep is a common bacteria that can be present in the vaginal or rectal area and is not sexually transmitted. Antibiotics during labor are given to prevent the baby from contracting the bacteria during delivery.
You are performing assessments for an obstetric patient who is 5 months pregnant with her third child. Which finding would cause you to suspect that the patient was at risk?
- A. Patient states that she doesn't feel any Braxton Hicks contractions like she had in her prior pregnancies.
- B. Fundal height is below the umbilicus.
- C. Cervical changes, such as Goodell's sign and Chadwick's sign, are present.
- D. She has increased vaginal secretions.
Correct Answer: B
Rationale: The correct answer is B: Fundal height is below the umbilicus. At 5 months pregnant with her third child, fundal height should be at or above the level of the umbilicus. A fundal height below the umbilicus may indicate intrauterine growth restriction or other fetal growth issues. This finding suggests a potential risk to the pregnancy's progress.
Incorrect Choices:
A: Patient not feeling Braxton Hicks contractions is common and not necessarily indicative of risk.
C: Presence of cervical changes like Goodell's and Chadwick's signs are expected physiological changes in pregnancy and do not necessarily indicate risk.
D: Increased vaginal secretions can be normal during pregnancy and do not necessarily signify a risk.
The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
- A. During labor, when she can no longer talk through contractions
- B. During the first stage of labor, when the contractions are 3 to 4 minutes apart
- C. Between contractions, during the transitional phase of the first stage of labor
- D. Between her efforts to push to facilitate relaxation between contractions
Correct Answer: A
Rationale: The correct answer is A: During labor, when she can no longer talk through contractions. This is the best time to encourage slow, deep chest breathing as it helps the laboring patient stay calm, focused, and manage pain effectively during the intense active phase of labor. When a woman reaches the point where she can no longer talk through contractions, it indicates that she is in the active phase of labor and may benefit from slow, deep breathing to help cope with the intensity of contractions.
Explanation for why other choices are incorrect:
B: During the first stage of labor, when the contractions are 3 to 4 minutes apart - Contractions being 3 to 4 minutes apart may not necessarily indicate the active phase of labor requiring slow, deep breathing.
C: Between contractions, during the transitional phase of the first stage of labor - Transitional phase contractions are typically intense and close together, making it less ideal for relaxation breathing between contractions.
D: Between her efforts
A pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient's plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: The correct answer is B: Refer to the physician for additional testing. When a triple-screen test is positive in a pregnant patient, it indicates an increased risk of certain conditions such as neural tube defects or chromosomal abnormalities. Therefore, the appropriate course of action is to refer the patient to a physician for further diagnostic testing, such as amniocentesis or ultrasound, to confirm or rule out these conditions.
Choice A is incorrect because a positive result on a triple-screen test does not indicate that results are normal; it suggests the need for further investigation. Choice C is incorrect because validating the results with the lab facility does not address the need for additional diagnostic testing. Choice D is incorrect because waiting 2 weeks to repeat the test and returning for a regular prenatal visit may delay necessary interventions or treatment for the patient.
When caring for a woman whom a nurse suspects is being abused by her partner, the nurse should do which of the following?
- A. Ask the client directly about how she sustained her injuries.
- B. Counsel the client on how her behavior probably provoked the attack.
- C. Inform the client that the police must arrest her partner.
- D. Give the client a pamphlet with the names of matrimonial attorneys.
Correct Answer: A
Rationale: Directly asking about injuries helps assess the situation and provide appropriate support and resources.