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A woman is in the 'taking-hold phase' of the postpartum period. Which of the following behaviors would the nurse expect to see?
- A. The woman is on the telephone relating her experiences to family and friends.
- B. The woman asks for a meal tray and eats a variety of foods brought from home.
- C. The woman is interested in learning baby-care skills from the nurse.
- D. The woman takes a nap after each breastfeeding and each meal.
Correct Answer: C
Rationale: During the 'taking-hold phase,' the mother is typically eager to learn how to care for her newborn and may seek guidance from the nurse.
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A woman who states that she smokes 2 packs of cigarettes each day is admitted to the labor and delivery suite in labor. The nurse should monitor this labor for which of the following?
- A. Delayed placental separation.
- B. Late decelerations.
- C. Shoulder dystocia.
- D. Precipitous fetal descent.
Correct Answer: B
Rationale: Smoking during pregnancy is associated with placental insufficiency, which can lead to late decelerations in the fetal heart rate.
A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.)
- A. Patient satisfaction level
- B. Hospital readmission rates
- C. Nursing hours per patient day
- D. Patient falls/falls with injuries
Correct Answer: C
Rationale: The American Nurses Association developed the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate nursing-sensitive outcomes with the purpose of improving patient safety and quality care. Nursing quality indicators include the following: Hospital readmission rates, nursing hours per patient day, and patient falls/falls with injuries. While every major health care organization measures certain aspects of patient satisfaction, it is not a nursing quality indicator.
The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
- A. Evaluate need for Rh0D immunoglobulin
- B. Clean site
- C. Administer pain medication
- D. Perform vital signs
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn.
Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.
A 32-week-gravid client presents in the emergency department with severe abdominal pain, rigid abdomen, and scant dark red bleeding. The nurse should assess this client for which of the following?
- A. Signs of pulmonary edema.
- B. Enlarging abdominal girth measurements.
- C. Hyporeflexia and confusion.
- D. Signs of diabetic coma and ketosis.
Correct Answer: B
Rationale: Severe abdominal pain, rigidity, and dark red bleeding could indicate placental abruption, which may cause enlarging abdominal girth due to internal bleeding.
A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: Step 1: The baseline fetal heart rate is 135 bpm, which is within the normal range of 110-160 bpm.
Step 2: The four nonepisodic patterns of fetal heart rate reaching 160 bpm for 20-25 seconds each indicate accelerations, a positive sign.
Step 3: A reactive NST requires at least two accelerations of the fetal heart rate within a 20-minute window, which this scenario meets.
Step 4: Therefore, the nurse will record these findings as NST reactive, reassuring because the fetal heart rate responded appropriately to stimuli.
Summary of Other Choices:
A: NST positive, nonreassuring - Inaccurate, as the findings indicate a reassuring response.
B: NST negative, reassuring - Incorrect, as the test results are actually reactive, not negative.
D: NST nonreactive, nonreassuring - Wrong, as the test is reactive and reassuring, not nonreactive and nonreassuring.