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The nurse is preparing a client for a biophysical profile (BPP). What does this test evaluate?
- A. Maternal blood flow to the placenta.
- B. Fetal genetic abnormalities.
- C. Fetal well-being, including movements and amniotic fluid.
- D. Cervical dilation and effacement.
Correct Answer: C
Rationale: The correct answer is C: Fetal well-being, including movements and amniotic fluid. A Biophysical Profile evaluates the fetus' health by assessing factors like fetal movements, muscle tone, breathing movements, amniotic fluid volume, and fetal heart rate patterns. This test provides valuable information about the fetus' well-being and helps in determining the need for interventions or further monitoring.
Explanation of why the other choices are incorrect:
A: Maternal blood flow to the placenta is not evaluated by a Biophysical Profile.
B: Fetal genetic abnormalities are not assessed through a BPP; it focuses on the fetus' current well-being.
D: Cervical dilation and effacement are related to labor progress and not part of a BPP, which focuses on fetal well-being.
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A client at 35 weeks' gestation reports sharp abdominal pain and vaginal bleeding. What condition should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: The correct answer is B: Abruptio placentae. This condition presents with sharp abdominal pain and vaginal bleeding, typically occurring in the third trimester. It is caused by the premature separation of the placenta from the uterine wall. The pain is often severe due to the bleeding and can lead to fetal distress. Placenta previa (A) presents with painless vaginal bleeding, preterm labor (C) typically involves regular contractions and cervical changes, and chorioamnionitis (D) is characterized by fever and uterine tenderness.
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 educating a prenatal client about weight dysphoric disorder. Which statement by the client gain during pregnancy. Which statement by the would require immediate follow-up? client indicates effective understanding?
- A. I have been crying the week of my period.
- B. I should gain 2 to 4 pounds in the first trimester
- C. I am experiencing suicidal thoughts. and half a pound per week in the last two
- D. My menstrual cycle is 1 week late. trimesters.
Correct Answer: C
Rationale: Correct Answer: C. "I am experiencing suicidal thoughts."
Rationale: This statement indicates a serious mental health concern that requires immediate follow-up. Suicidal thoughts during pregnancy can be a sign of depression or other mental health issues that need to be addressed promptly to ensure the safety and well-being of the client and the baby.
Summary of Other Choices:
A: "I have been crying the week of my period." - This statement suggests premenstrual symptoms which are common and not necessarily alarming during pregnancy.
B: "I should gain 2 to 4 pounds in the first trimester and half a pound per week in the last two trimesters." - This statement reflects a correct understanding of weight gain recommendations during pregnancy and does not raise immediate concerns.
D: "My menstrual cycle is 1 week late." - This statement is not concerning during pregnancy as menstrual cycles typically stop during pregnancy.
A woman had a miscarriage at 12 weeks' gestation and had D&C,
- A. While you are assessing her response to loss, she tells you she had
- B. Based on your assessment what nursing intervention would you use first?
- C. You ask her what items she bought for the baby
Correct Answer: B
Rationale: The correct answer is B because the priority in nursing care after a miscarriage and D&C is to assess the woman's physical and emotional well-being. By using the nursing intervention of assessment first, the nurse can determine any immediate needs for pain management, emotional support, or further medical intervention. This helps in providing individualized care and addressing any potential complications promptly.
Choice A is incorrect because assessing her response to loss comes after ensuring her immediate physical and emotional needs are met. Choice C is incorrect as it focuses on material items rather than the woman's well-being. Choice D is incomplete and does not provide a viable option for nursing intervention.
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.