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The nurse is performing the interval history on a patient at 30 weeks of gestation. What data would the prenatal nurse bring to the attention of the health-care provider?
- A. Hgb change from 12 g/dL (at first prenatal visit) to 11 g at 28 weeks
- B. negative ketones in the urine
- C. dysuria for 3 days
- D. weight gain of 3 pounds in the last 2 weeks
Correct Answer: C
Rationale: Rationale: Choice C (dysuria for 3 days) is the correct answer as it could indicate a urinary tract infection (UTI) which can lead to complications during pregnancy. Dysuria may be a sign of UTI, which can progress quickly in pregnant women. Bringing this to the health-care provider's attention is essential for prompt treatment to prevent potential harm to both the mother and baby.
Summary of other choices:
A: Hgb change is within normal range for pregnancy, not necessarily alarming.
B: Negative ketones in the urine are expected and indicate adequate glucose utilization.
D: Weight gain of 3 pounds in 2 weeks is considered normal in the third trimester and not typically a cause for concern unless sudden or excessive.
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A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: Step 1: The baseline fetal heart rate is 135 bpm, which is within the normal range of 110-160 bpm.
Step 2: The four nonepisodic patterns of fetal heart rate reaching 160 bpm for 20-25 seconds each indicate accelerations, a positive sign.
Step 3: A reactive NST requires at least two accelerations of the fetal heart rate within a 20-minute window, which this scenario meets.
Step 4: Therefore, the nurse will record these findings as NST reactive, reassuring because the fetal heart rate responded appropriately to stimuli.
Summary of Other Choices:
A: NST positive, nonreassuring - Inaccurate, as the findings indicate a reassuring response.
B: NST negative, reassuring - Incorrect, as the test results are actually reactive, not negative.
D: NST nonreactive, nonreassuring - Wrong, as the test is reactive and reassuring, not nonreactive and nonreassuring.
The nurse has received change of shift report on the following four clients. Which of the clients should the nurse assess first?
- A. G1 P0000, 9 weeks’ gestation, hyperemesis gravidarum, vomited twice during the last shift.
- B. G2 P0101, 24 weeks’ gestation, receiving terbutaline po q 2 h for preterm labor, no complaints of cramping during last shift.
- C. G1 P0000, 1 day postpartum, vacuum extraction, for bilateral tubal ligation during this shift.
- D. G2 P0101, 2 days postpartum, spontaneous delivery, had asthma attack during last shift.
Correct Answer: D
Rationale: The client who had an asthma attack during the last shift should be assessed first due to the potential for respiratory complications.
A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.)
- A. Patient satisfaction level
- B. Hospital readmission rates
- C. Nursing hours per patient day
- D. Patient falls/falls with injuries
Correct Answer: C
Rationale: The American Nurses Association developed the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate nursing-sensitive outcomes with the purpose of improving patient safety and quality care. Nursing quality indicators include the following: Hospital readmission rates, nursing hours per patient day, and patient falls/falls with injuries. While every major health care organization measures certain aspects of patient satisfaction, it is not a nursing quality indicator.
The nurse is caring for a client and her partner who just birthed a 33-week fetal demise. Which of the following actions by the nurse is appropriate at this time?
- A. Recommend that the woman be moved to a medical unit.
- B. Refrain from discussing the loss with the couple.
- C. Ask the couple if they would like to hold their baby.
- D. Obtain an order for a milk suppressant for the mother.
Correct Answer: C
Rationale: Allowing the couple to hold their baby facilitates the grieving process and provides closure.
The nurse is preparing to teach a client how to perform daily fetal kick counts. Which instruction is most important for the nurse to give the client?
- A. Count fetal kicks prior to eating a meal
- B. Lie on back when counting kicks
- C. Call provider if at least three movements are not felt in 1 hour
- D. Count all movements over 1 hour
Correct Answer: C
Rationale: The correct answer is C: Call provider if at least three movements are not felt in 1 hour. This instruction is crucial because decreased fetal movements can indicate potential fetal distress. By advising the client to contact the healthcare provider if fewer than three movements are felt in an hour, the nurse is emphasizing the importance of promptly seeking medical attention when there may be a concern for the baby's well-being.
A: Counting kicks prior to eating a meal is not as important as monitoring the baby's movements consistently throughout the day.
B: Lying on the back when counting kicks is not recommended, as it can reduce blood flow to the uterus and potentially affect the baby.
D: Counting all movements over 1 hour may not capture a decrease in movements that could be a cause for concern, as the focus should be on monitoring a specific minimum number of movements within a set timeframe.
In summary, the correct answer emphasizes the need for prompt action in case of decreased fetal movements, while