Nokea
The experienced nurse is instructing the new nurse about communications concerning the patient. The nurse suggests using an SBAR method and lists the four elements included in the technique. Which four elements should be included in the instruction?
- A. Shift-end report, background, assessment, and reassessment
- B. Situation, background, assessment, and recommendation
- C. Shift-end report, background, assessment, and recommendation
- D. Situation, background, actual nursing diagnoses, and remedy
Correct Answer: B
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. This method is widely used in healthcare settings to ensure clear and concise communication.
You may also like to solve these questions
To reassure and educate pregnant patients about changes in the cervix, vagina, and position of the fetus, nurses should be aware that:
- A. because of a number of changes in the cervix, abnormal Papanicolaou (Pap) tests are much easier to evaluate
- B. Quickening is a technique of palpating the fetus to engage it in passive movement
- C. the deepening color of the vaginal mucosa and cervix (Chadwick's sign) usually appears in the second trimester or later as the vagina prepares to stretch during labor
- D. increased vascularity of the vagina increases sensitivity and may lead to a high degree of arousal, especially in the second trimester
Correct Answer: D
Rationale: Increased vascularity and sensitivity in the vagina are common during pregnancy. Chadwick's sign appears earlier (6-8 weeks), and quickening refers to maternal perception of fetal movement.
Physiologic anemia often occurs during pregnancy as a result of:
- A. inadequate intake of iron.
- B. dilution of hemoglobin concentration.
- C. the fetus establishing iron stores.
- D. decreased production of erythrocytes.
Correct Answer: B
Rationale: Physiologic anemia during pregnancy occurs due to the expansion of plasma volume, causing a dilution of hemoglobin concentration. Increased blood volume is necessary to support the growing fetus, leading to a relative decrease in hemoglobin levels. Inadequate iron intake (Choice A) can cause iron-deficiency anemia but is not the primary reason for physiologic anemia in pregnancy. The fetus establishing iron stores (Choice C) is unrelated to the maternal anemia. Decreased production of erythrocytes (Choice D) is not the main cause of anemia in pregnancy; rather, it is the dilution effect from increased plasma volume.
Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester?
- A. Less audible heart sounds (S1, S2)
- B. Increased pulse rate
- C. Decreased red blood cell (RBC) production
- D. Increased blood pressure
Correct Answer: B
Rationale: During the second trimester, the pulse rate increases by 10-15 beats per minute, while blood pressure typically decreases slightly due to hormonal and circulatory changes.
A patient at 24 weeks of gestation contacts the nurse at her obstetric provider's office to complain that she has cravings for dirt and gravel. The nurse is aware that this condition is known as and may indicate anemia.
- A. ptyalism
- B. pyrosis
- C. pica
- D. decreased peristalsis
Correct Answer: C
Rationale: Pica, the craving for nonfood substances, is often associated with iron deficiency anemia and should be evaluated.
To reassure and educate pregnant patients about changes in their cardiovascular system, maternity nurses should be aware that:
- A. a pregnant woman experiencing disturbed cardiac rhythm, such as sinus arrhythmia requires close medical and obstetric observation, no matter how healthy she otherwise may appear.
- B. changes in heart size and position and increases in blood volume create auditory changes from 20 weeks to term.
- C. palpitations are twice as likely to occur in twin gestations.
- D. all of the above changes will likely occur.
Correct Answer: D
Rationale: The correct answer is D because all the statements in choices A, B, and C are true regarding changes in the cardiovascular system during pregnancy.
A: Pregnant women with disturbed cardiac rhythm, such as sinus arrhythmia, should be closely monitored as it can impact both the mother and the fetus, regardless of the mother's overall health status.
B: Changes in heart size, position, and blood volume lead to auditory changes from 20 weeks to term, which is important for nurses to be aware of in order to monitor the cardiovascular health of pregnant patients.
C: Palpitations are more likely to occur in twin gestations due to the increased demands on the cardiovascular system.
In summary, all the changes mentioned in choices A, B, and C are common occurrences in pregnancy and it is crucial for maternity nurses to be aware of them in order to provide appropriate care and education to pregnant patients.