Nokea
In the assessing the health condition of the preganant patient, Nurse Vera should focus on the _________.
- A. last menstrual period
- B. number of days of menstruation
- C. age of patient during menarche
- D. amount of menstrual flow
Correct Answer: A
Rationale: Nurse Vera should focus on the last menstrual period when assessing the health condition of the pregnant patient because it is crucial for determining the estimated due date of the pregnancy. Knowing the date of the last menstrual period allows healthcare providers to calculate the gestational age of the fetus, monitor the progress of the pregnancy, and identify any potential issues or complications that may arise. Additionally, the last menstrual period is necessary for accurate dating of the pregnancy and scheduling prenatal care visits and screenings. By focusing on the last menstrual period, Nurse Vera can gather important information that will guide the management and care of the pregnant patient.
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A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
- A. Administering naloxone prophylactically
- B. Monitoring oxygen saturation with pulse oximetry
- C. Encouraging deep breathing exercises
- D. Administering bronchodilators as needed
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.
A patient presents with pallor, fatigue, and dyspnea on exertion. Laboratory tests reveal a low hemoglobin level, low MCV, and elevated red blood cell distribution width (RDW). Which of the following conditions is most likely to cause these findings?
- A. Iron deficiency anemia
- B. Thalassemia
- C. Anemia of chronic disease
- D. Megaloblastic anemia
Correct Answer: A
Rationale: #NAME?
The nurse explains to the mother that the uterus will return to its pre pregnancy state in _____ weeks.
- A. Six
- B. Three
- C. Four
- D. five
Correct Answer: C
Rationale: The nurse explains to the mother that the uterus will return to its pre-pregnancy state in about four to six weeks after giving birth. This timeframe is an average estimation of how long it takes for the uterus to shrink back to its normal size and position after going through the process of supporting and nourishing a developing fetus. The process of the uterus returning to its pre-pregnancy state is known as involution, where the uterus undergoes contractions to shed the excess lining and reduce in size. This period is crucial for the body to heal and recover from the changes that occurred during pregnancy and childbirth.
A woman in active labor experiences persistent fetal malposition, with the fetus in a transverse lie presentation. What nursing intervention should be prioritized to address this abnormal labor presentation?
- A. Facilitating external cephalic version (ECV)
- B. Assisting the mother into a hands-and-knees position
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: B
Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.
After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?
- A. "I will wipe the area from front to back using blotting motion "
- B. "I will put ice packs on the site 15 minutes once a day for 3 to 4 days"
- C. "Before bedtime, I will do a cold water sitz bath"
- D. "I'll use sudsy water to clean the episiotomy"
Correct Answer: A
Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.