Nokea
The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed
- C. Patient will state an absence of pain 1 hour after administration of the prescribed
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
Correct Answer: D
Rationale: The correct answer is D because it reflects a specific, measurable, and realistic expected outcome for the nursing diagnosis of acute pain. It includes the patient's subjective pain rating (2 on a scale of 10) and a time frame (1 hour after administration of medication). This outcome is achievable and provides a clear target for evaluating the effectiveness of pain management.
Option A is incorrect as it does not specify a time frame or intervention. Option B is vague and lacks a measurable outcome. Option C is also vague and lacks a clear time frame for evaluation. Overall, option D is the best choice as it aligns with the SMART criteria for expected outcomes in nursing care planning.
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Which condition is the most life-threatening virus to the fetus and neonate?
- A. Hepatitis A virus (HAV)
- B. Herpes simplex virus (HSV)
- C. Hepatitis B virus (HBV)
- D. Cytomegalovirus (CMV)
Correct Answer: C
Rationale: Hepatitis B virus (HBV) poses the most significant threat to the fetus and neonate.
Which patient may require more help and understanding when integrating the newborn into the family?
- A. A primipara from an upper income family
- B. A primipara who comes from a large family
- C. A multipara (gravida 2) who has a supportive husband and mother
- D. A multipara (gravida 6) who has two children younger than 3 years
Correct Answer: D
Rationale: The correct answer is D because a multipara with six pregnancies and two young children may require more help and understanding due to the potential challenges of caring for multiple young children simultaneously. The presence of two children younger than 3 years old indicates that the mother may be experiencing higher levels of stress and demands on her time and energy. This situation could lead to difficulties in integrating the newborn into the family dynamics.
Choice A is incorrect because being from an upper-income family does not necessarily indicate a need for more help and understanding. Choice B is incorrect because coming from a large family does not directly correlate with requiring more assistance when integrating a newborn. Choice C is incorrect because having a supportive husband and mother can provide valuable assistance and may not necessarily indicate a greater need for help compared to the scenario described in choice D.
Maternity nurses can enhance communication among health care providers by using the SBAR technique. The acronym SBAR stands for what?
- A. Situation, background, assessment, recommendation
- B. Situation, baseline, assessment, recommendation
- C. Subjective, background, analysis, recommendation
- D. Subjective, background, analysis, review
Correct Answer: A
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation, which is a communication technique for providing important information.
Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. Which physiologic alteration is the cause for the diaphoresis and diuresis that this client is experiencing?
- A. Elevated temperature caused by postpartum infection
- B. Increased basal metabolic rate after giving birth
- C. Loss of increased blood volume associated with pregnancy
- D. Increased venous pressure in the lower extremities
Correct Answer: C
Rationale: Diaphoresis and diuresis are mechanisms for reducing excess tissue fluid accumulated during pregnancy.
A nurse is entering information on the patient’s electronic health record (EHR) and is called to assist in an emergency situation with regard to another patient in the labor and birth suite. The nurse rushes to the scene to assist; however, she leaves the chart open on the computer screen. The emergent patient situation is resolved satisfactorily, and the nurse comes back to the computer entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with the nurse and tells her that she is concerned with what happened today on the unit because there was a breach in confidentiality. Which response by the nurse indicates that she understands the nurse manager’s concerns?
- A. The nurse acknowledges that she should have made sure that her patient was safe before assisting with the emergency.
- B. The nurse states that she should have logged out of the EHR prior to attending to the emergency.
- C. The nurse indicates that the unit was understaffed.
- D. The nurse indicates that the she changed her password following the clinical emergency to maintain confidentiality.
Correct Answer: B
Rationale: The correct answer is B. The nurse should have logged out of the EHR prior to attending to the emergency. By leaving the EHR open and unattended, the nurse exposed patient information to potential unauthorized access, violating patient confidentiality. Logging out would have prevented this breach.
Choice A is incorrect because the priority in an emergency is to address the immediate patient needs. Choice C is irrelevant to the breach of confidentiality. Choice D, changing the password after the incident, does not address the initial breach and is not a sufficient response to the nurse manager's concerns about maintaining confidentiality.