Nokea
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: The correct answer is B: generating solutions. In the CJMM (Clinical Judgment Model in Nursing), developing a plan to achieve patient outcomes falls under the step of generating solutions. This step involves identifying and implementing interventions to address the patient's needs and achieve the desired outcomes. Prioritizing hypotheses (A) is about identifying potential issues, not developing a plan. Taking action (C) is about implementing the plan, not developing it. Evaluating outcomes (D) is the final step where the effectiveness of the plan is assessed, not where the plan is developed. Therefore, B is the correct choice as it specifically focuses on the process of creating a plan to achieve patient outcomes within the CJMM.
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What are signs of neonatal sepsis that a nurse should monitor for?
- A. Tachypnea, poor feeding, and temperature instability
- B. Increased alertness, reduced crying, and stable vitals
- C. Lethargy, poor perfusion, and apnea
- D. Hyperthermia, bradycardia, and cyanosis
Correct Answer: C
Rationale: The correct answer is C because lethargy, poor perfusion, and apnea are classic signs of neonatal sepsis. Lethargy indicates decreased activity and responsiveness, poor perfusion suggests inadequate blood circulation, and apnea is a serious respiratory issue. These signs indicate a systemic infection affecting multiple organs. Choices A, B, and D do not align with typical symptoms of neonatal sepsis. Tachypnea, poor feeding, and temperature instability (Choice A) are more general and can be seen in various conditions. Increased alertness, reduced crying, and stable vitals (Choice B) are not indicative of sepsis, as sepsis typically causes the opposite. Hyperthermia, bradycardia, and cyanosis (Choice D) can be present in sepsis, but they are not as specific or as common as the signs in Choice C.
The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.
What is the best position for a laboring mother with a suspected occiput posterior position?
- A. Encourage side-lying position
- B. Place the mother in lithotomy position
- C. Encourage ambulation to facilitate descent
- D. Use a peanut ball to widen the pelvis
Correct Answer: D
Rationale: The correct answer is D. Using a peanut ball widens the pelvis, which can help rotate the baby into an optimal position for birth. This position can aid in reducing the likelihood of prolonged labor and the need for interventions. Encouraging side-lying position (A) may not provide the necessary pelvic widening. Placing the mother in lithotomy position (B) can impede the baby's descent. Encouraging ambulation (C) may not specifically address the occiput posterior position and may not provide enough pelvic opening.
The nurse is monitoring a client in labor and suspects hypertonic uterine contractions. What is the priority nursing action?
- A. Provide pain relief measures.
- B. Prepare the client for an amniotomy.
- C. Promote ambulation every 30 minutes.
- D. Monitor the oxytocin infusion closely.
Correct Answer: A
Rationale: The correct answer is A: Provide pain relief measures. In hypertonic uterine contractions, the uterus contracts too frequently and intensely, leading to increased pain and potential fetal distress. Providing pain relief helps alleviate discomfort for the client and may reduce the risk of fetal distress. Other choices are incorrect because: B) Amniotomy may not be necessary and could potentially worsen the situation. C) Ambulation may not be safe or effective during hypertonic contractions. D) Monitoring the oxytocin infusion closely is important but not the priority in managing hypertonic contractions.