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A woman is being interviewed by a triage nurse at a medical doctor's office. Which of the following signs/symptoms by the client would warrant the nurse to suggest that a pregnancy test be done? Select all that apply.
- A. Amenorrhea.
- B. Fever.
- C. Fatigue.
- D. Nausea.
Correct Answer: A
Rationale: Amenorrhea, fatigue, and nausea are common early signs of pregnancy. Fever is not typically associated with pregnancy and may indicate an infection.
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What assessments or tests would the nurse inform the pregnant patient they can expect to have at each prenatal visit?
- A. hemoglobin
- B. antibody screen
- C. ultrasound
- D. blood pressure
Correct Answer: D
Rationale: The correct answer is D: blood pressure. Monitoring blood pressure is essential during prenatal visits to detect any signs of preeclampsia or high blood pressure, which can be harmful to both the mother and baby. Regular blood pressure checks help ensure the health and well-being of the pregnant patient.
Rationale:
- A: Hemoglobin levels are typically checked to assess for anemia, but this may not be done at every prenatal visit unless there are specific concerns.
- B: Antibody screen is usually done early in pregnancy to check for antibodies that could affect the baby, but it may not be part of routine prenatal visits.
- C: Ultrasound is an important test during pregnancy, but it is not typically done at every prenatal visit unless there are specific concerns or for routine screening.
Summary:
Regular monitoring of blood pressure is crucial during prenatal visits to ensure the well-being of the pregnant patient. Hemoglobin, antibody screen, and ultrasound may not be done at every visit unless there are
A mother, 39 weeks’ gestation, is admitted to the labor suite with rupture of membranes 15 minutes earlier and contractions q 8 minutes × 30 seconds. On vaginal exam, the cervix is 4 cm dilated and 80% effaced, and the station is –2. The baby is found to be in the LSP position. The fetal heart rate is 144 with average variability and variable decelerations. Which of the following complications of labor must the nurse assess this client for at this time?
- A. Precipitous delivery.
- B. Chorioamnionitis.
- C. Uteroplacental insufficiency.
- D. Prolapsed cord.
Correct Answer: D
Rationale: LSP (left sacrum posterior) position and rupture of membranes increase the risk of a prolapsed umbilical cord, which is a medical emergency.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
The nurse is counseling a woman who has been diagnosed with mild osteoporosis. Which of the following should be included in the counseling session?
- A. Begin a regimen of walking each day.
- B. Refrain from drinking chocolate milk.
- C. Increase her daily intake of red meat.
- D. Only wear shoes with rubber soles.
Correct Answer: A
Rationale: Weight-bearing exercises like walking can help strengthen bones and reduce the risk of fractures in individuals with osteoporosis.
Which of the following complications of labor and delivery may develop when a baby enters the pelvis in the LMP position?
- A. Cephalopelvic disproportion.
- B. Placental abruption.
- C. Breech presentation.
- D. Acute fetal distress.
Correct Answer: A
Rationale: LMP (left mentum posterior) position can lead to cephalopelvic disproportion, making delivery difficult.