Nokea
The nurse is formulating a nursing care plan for a postpartum patient. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply.)
- A. Using a standardized postpartum care plan
- B. Determining priorities for each diagnosis written
- C. Writing interventions from a nursing diagnosis book
- D. Reflecting and suspending judgment when writing the care plan
Correct Answer: B
Rationale: B. Determining priorities for each diagnosis written: Prioritizing nursing diagnoses based on the patient's needs and condition requires critical thinking skills. The nurse must be able to identify the most urgent issues to address first in the care plan.
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A 48-year-old female patient presents to the OB/GYN clinic for her annual examination. She states that she has had the following symptoms: mood swings, irregular menstrual cycles, forgetfulness, food cravings, and a decrease in libido. Which of the following does the nurse suspect the patient is experiencing?
- A. Menopause
- B. Perimenopause
- C. Postmenopause
- D. Pregnancy
Correct Answer: B
Rationale: Perimenopause is the transitional period leading to menopause that usually begins in a woman's 40s but can start earlier. During this phase, women may experience symptoms such as mood swings, irregular menstrual cycles, forgetfulness, food cravings, and a decrease in libido, as described by the patient in this case. These symptoms are caused by hormonal fluctuations as the ovaries start to produce less estrogen in preparation for menopause. Menopause occurs when a woman has not had a menstrual period for 12 consecutive months. Postmenopause, on the other hand, refers to the stage after menopause, where menopausal symptoms have generally subsided. The symptoms described by the patient are more indicative of the perimenopausal stage rather than pregnancy, as they are typical signs of hormonal changes associated with the menopausal transition.
A college-aged female patient states that she understands the risk of sexual assault with overdrinking. She asks the nurse what health risks are associated with excessive alcohol intake for her age. What diseases or conditions should the nurse include in her response? Select all that
apply
- A. Infertility
- B. Cancer of mouth
- C. Hypertension
- D. Brain shrinkage
Correct Answer: A
Rationale: A. Excessive alcohol intake is a risk factor for developing cancer, particularly cancers of the mouth, throat, esophagus, liver, and breast. Chronic alcohol use can increase the individual's susceptibility to these types of cancers.
The nurse is preparing to teach the community about risk factors for the second most common cancer of the female reproductive system. Which of the following groups of women are at higher risk for this cancer? Select all that apply.
- A. Menopausal women with an intact uterus who receive hormonal therapy
- B. Women who have undergone treatment for breast cancer
- C. Women who have many pregnancies and nursed their infants
- D. Women who smoke and have many sexual partners
Correct Answer: A
Rationale: A. Menopausal women with an intact uterus who receive hormonal therapy are at higher risk for endometrial cancer, which is the second most common cancer of the female reproductive system. Estrogen therapy without progesterone can increase the risk of endometrial cancer due to unopposed estrogen stimulation.
A nurse is caring for a pregnant patient who asks when she should be tested for GBS. What does the nurse tell the patient?
- A. 34–35 weeks
- B. 36–37 weeks
- C. 38–39 weeks
- D. 39–40 weeks
Correct Answer: B
Rationale: The nurse should inform the pregnant patient that Group B Streptococcus (GBS) testing is typically done between 36 and 37 weeks of pregnancy. Testing at this time allows for optimal identification of GBS colonization during childbirth. It is important to test at this stage to determine the presence of GBS in the birth canal, as GBS can be passed to the newborn during delivery, which may lead to serious infections. Testing later in pregnancy increases the likelihood of obtaining accurate results closer to the due date, enabling appropriate management to be implemented to reduce the risk of transmission to the newborn.
A nurse is working in the area of labor and birth. Her assignment is to take care of a gravida 1 para 0 woman who presents in early labor at term. Vaginal exam reflects the following: 2 cm, cervix posterior, –1 station, and vertex with membranes intact. The patient asks the nurse if she can break her water so that her labor can go faster. The nurse’s response, based on the ethical principle of nonmaleficence, is which of the following?
- A. Tell the patient that she will have to wait until she has progressed further on the vaginal exam and then she will perform an amniotomy.
- B. Have the patient write down her request and then call the physician for an order to implement the amniotomy.
- C. Instruct the patient that only a physician or certified midwife can perform this procedure.
- D. Give the patient an enema to stimulate labor.
Correct Answer: A
Rationale: The correct response based on the ethical principle of nonmaleficence, which refers to the duty to do no harm, is to tell the patient that she will have to wait until she has progressed further on the vaginal exam and then perform an amniotomy. In this scenario, breaking the patient's water prematurely could introduce risks and potential harm without clear medical necessity. Performing an amniotomy too early could increase the risk of infection or cause umbilical cord prolapse, which can be harmful to both the mother and the baby. Therefore, it is important for the nurse to wait until the patient has progressed further in labor before considering an amniotomy.