Nokea
The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
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What statement by a health-care provider is an example of shared decision making between a health-care provider and a patient?
- A. I'm going to start this medication because it is best for your baby.
- B. Can you agree with me because I am your health-care provider?â€
- C. I understand how the hospital works, and it will be easier for you to just do what is easy for the nurses.â€
- D. Do you feel ready to make a decision after we talked about this medication?â€
Correct Answer: D
Rationale: The correct answer is D because it involves the patient in the decision-making process by asking for their readiness to make a decision after discussing the medication. This approach respects the patient's autonomy and encourages them to actively participate in their healthcare choices.
A is incorrect as it does not involve the patient in the decision-making process but rather imposes the provider's choice. B is incorrect as it uses authority to influence the patient's decision, which is not in line with shared decision making. C is incorrect as it focuses on convenience rather than involving the patient in the decision-making process.
The nurse is educating a client about folic acid during pregnancy. What food should the nurse recommend?
- A. Citrus fruits.
- B. Leafy green vegetables.
- C. Dairy products.
- D. Lean meats.
Correct Answer: B
Rationale: The correct answer is B: Leafy green vegetables. Folic acid is essential during pregnancy for proper fetal development. Leafy green vegetables like spinach, kale, and broccoli are rich sources of folic acid. Citrus fruits (Choice A) contain vitamin C but not as much folic acid as leafy greens. Dairy products (Choice C) provide calcium but are not significant sources of folic acid. Lean meats (Choice D) are good sources of protein but do not contain as much folic acid as leafy green vegetables. Therefore, recommending leafy green vegetables ensures the client gets an adequate intake of folic acid during pregnancy.
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.
What question during a family assessment could the nurse ask to determine if the family has necessary resources?
- A. Do you enjoy spending time with your family?
- B. Do you have a group of friends, neighbors, or a church that helps you when you are ill?
- C. How often do you go to the store by yourself?
- D. Do your family members get along well?
Correct Answer: B
Rationale: The correct answer is B: "Do you have a group of friends, neighbors, or a church that helps you when you are ill?" This question assesses the family's support network and resources in times of need. It helps determine if the family has a social support system that can provide assistance during challenging situations. Options A, C, and D are incorrect as they do not directly address the availability of external resources for the family's well-being. Option A focuses on emotional aspects, C on independence, and D on family dynamics, which are not directly related to assessing resources.
The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.