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The nurse receives a phone call from a patient concerned about the results of the laboratory tests obtained at the first prenatal visit 10 days ago. What is the nurse's next action?
- A. ask the patient if they have checked their electronic chart
- B. inform the patient they will need to wait until the next office visit for the results
- C. provide the patient with the results of the tests
- D. verify the identification of the patient
Correct Answer: D
Rationale: The correct answer is D: verify the identification of the patient. This is crucial to ensure patient safety and confidentiality. By verifying the patient's identity, the nurse can confirm they are providing the correct information to the right person, preventing potential errors or breaches of confidentiality. Asking about the electronic chart (A) is unnecessary if the identity is not confirmed. Informing the patient to wait (B) does not address the immediate concern. Providing results (C) without proper identification can lead to miscommunication. Hence, verifying the patient's identification is the first step to address the patient's concerns effectively.
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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.
The nurse is performing Leopold's maneuvers on a pregnant patient at 36 weeks of gestation and determines the fetal lie is longitudinal, palpates the fetal legs in the top of the uterus, and palpates the fetal head above the symphysis pubis. Which fetal presentation does the nurse document in the EHR?
- A. cephalic
- B. compound
- C. transverse
- D. breech
Correct Answer: D
Rationale: The correct answer is D: breech. At 36 weeks of gestation, if the nurse palpates the fetal head above the symphysis pubis and the fetal legs are at the top of the uterus, it indicates a breech presentation where the baby's buttocks or feet are positioned to be delivered first. In a breech presentation, the fetal head is not engaged in the pelvis and is palpable above the symphysis pubis. The longitudinal lie with the fetal legs on top further supports the breech presentation.
Summary:
A: Cephalic presentation would have the fetal head engaged in the pelvis.
B: Compound presentation involves an additional body part alongside the presenting part.
C: Transverse lie would have the baby positioned horizontally across the uterus.
D: Breech presentation aligns with the given scenario of palpating fetal legs on top and head above the symphysis pubis.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
A fetus, descending through the birth canal, is going through the cardinal moves of labor. Please place the following moves in chronological order.
- A. External rotation.
- B. Flexion.
- C. Extension.
- D. Internal rotation.
Correct Answer: D
Rationale: The cardinal movements of labor occur in the following order: flexion, internal rotation, extension, external rotation, and expulsion.
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?
- A. Hemophilia
- B. Sickle cell anemia
- C. A neural tube defect
- D. Abnormal lecithin-to-sphingomyelin ratio
Correct Answer: C
Rationale: The correct answer is C: A neural tube defect. Elevated AFP levels in maternal serum are indicative of neural tube defects in the fetus. AFP is produced by the fetal liver and yolk sac, and high levels may suggest a defect in the development of the neural tube. Hemophilia (A), sickle cell anemia (B), and abnormal lecithin-to-sphingomyelin ratio (D) do not directly correlate with AFP levels. Hemophilia is a genetic blood disorder, sickle cell anemia is a genetic blood disorder affecting hemoglobin, and abnormal lecithin-to-sphingomyelin ratio is related to fetal lung maturity.