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In which type of health care facility does the nurse want to work if applying for a position with a home care organization that specializes in spinal cord injury?
- A. Secondary acute
- B. Continuing
- C. Restorative
- D. Tertiary
Correct Answer: C
Rationale: Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability.
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The nurse is obtaining the first postpartum meal for a client who has stated that she practices Mormonism (the Church of Jesus Christ of Latter-Day Saints). Which of the following items should the nurse remove from the clients’ food tray?
- A. Caffeinated coffee.
- B. Cheeseburger.
- C. Fried fish.
- D. Pork sausage.
Correct Answer: A
Rationale: Mormons typically avoid caffeinated beverages as part of their religious practices.
A patient who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition?
- A. Congenital anomalies
- B. Death before or after birth
- C. Neonatal hypoglycemia
- D. Neonatal withdrawal syndrome
Correct Answer: B
Rationale: The correct answer is B: Death before or after birth. Smoking during pregnancy increases the risk of fetal death, both before and after birth, due to the harmful effects of nicotine and other toxins on the developing fetus. Smoking can lead to complications such as placental abruption, preterm birth, low birth weight, and stillbirth.
A: Congenital anomalies - While smoking during pregnancy can increase the risk of certain birth defects, the primary concern related to smoking is not congenital anomalies.
C: Neonatal hypoglycemia - Smoking during pregnancy is not directly linked to neonatal hypoglycemia, which is usually related to maternal diabetes or other factors.
D: Neonatal withdrawal syndrome - Although smoking during pregnancy can lead to nicotine exposure in the fetus, resulting in withdrawal symptoms after birth, the immediate risk of death is a more critical concern associated with smoking during pregnancy.
A client’s vital signs during labor and delivery were: BP 100/58–110/66, T 98.6ºF–98.8ºF, P 72–80 bpm, R 20–24 rpm. The client’s vitals 2 hours postpartum are BP 100/56, TPR 99.4ºF, P 70 bpm, R 20 rpm. Which of the following actions should the nurse perform at this time?
- A. Check the client’s lochia flow.
- B. Ask the client if she is having chills.
- C. Encourage the client to drink fluids.
- D. Assess the client’s lung fields.
Correct Answer: A
Rationale: Checking the client’s lochia flow is important to ensure there is no excessive bleeding, which could indicate postpartum hemorrhage.
What is the purpose of initiating contractions in a contraction stress test (CST)?
- A. Increase placental blood flow.
- B. Identify fetal acceleration patterns.
- C. Determine the degree of fetal activity.
- D. Apply a stressful stimulus to the fetus.
Correct Answer: D
Rationale: The purpose of initiating contractions in a contraction stress test (CST) is to apply a stressful stimulus to the fetus to assess its response to stress, mimicking the stress of labor. This helps evaluate fetal well-being by monitoring the fetal heart rate during contractions. A: Increasing placental blood flow is not the primary purpose of CST. B: Identifying fetal acceleration patterns is not the main goal of CST. C: Determining the degree of fetal activity is not the primary objective of CST. The correct answer is D as it reflects the main purpose of initiating contractions in a CST.
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.