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The nurse is providing postoperative care to a patient who underwent a total abdominal hysterectomy 12 hours ago. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Assist the patient with ambulation.
- B. Maintain the Foley catheter for 48 to 72 hours postoperatively.
- C. Monitor intake and output and characteristics of urin
- D. urinary tract infection
Correct Answer: A
Rationale: A. Assist the patient with ambulation: Encouraging early ambulation after surgery helps prevent complications such as blood clots, pneumonia, and pressure ulcers. It also promotes circulation and aids in the recovery process.
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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.
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.
A nurse is caring for a patient who has HSV and is pregnant. The patient is concerned about the fetus. What medication is safest to take?
- A. valacyclovir
- B. none
- C. acyclovir
- D. famciclovir
Correct Answer: C
Rationale: Acyclovir is the antiviral medication of choice for treating HSV (Herpes Simplex Virus) infections during pregnancy due to its known safety profile. It is classified as Category B by the FDA, indicating that there is no evidence of risk to the fetus based on animal studies. Valacyclovir and famciclovir, on the other hand, are both classified as Category B (risk cannot be ruled out) and Category C (animal studies have shown adverse effects) by the FDA, respectively. It is generally recommended to avoid taking unnecessary medications during pregnancy, but if treatment for HSV is necessary, acyclovir is considered the safest option.
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.
Which statement best describes the advantage of a labor, birth, recovery, and postpartum (LDRP) room?
- A. The family is in a familiar environment.
- B. They are less expensive than traditional hospital rooms.
- C. The infant is removed to the nursery to allow the mother to rest.
- D. The woman’s support system is encouraged to stay until discharge.
Correct Answer: A
Rationale: One of the advantages of a labor, birth, recovery, and postpartum (LDRP) room is that the family is in a familiar environment. LDRP rooms are designed to provide a comfortable setting where the mother, baby, and family can stay together throughout the entire childbirth process. This environment allows for better continuity of care, enhances bonding between the baby and the family, and helps reduce stress and anxiety often associated with being in an unfamiliar hospital setting. Being in a familiar environment can also promote a sense of security and control for the mother, which can positively impact her overall birthing experience.