Nokea
The primiparous patient that's 40 weeks' gestation reports to the nurse that she has increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?
- A. This symptom usually means the baby's head has descended further
- B. Unless you have pain with urination, we don't need to worry it
- C. Come in for an appointment today and we'll check out everything
- D. This might indicate that the baby is no longer in a head down position
Correct Answer: A
Rationale: The best response by the nurse is to reassure the primiparous patient that her increased pelvic pressure and urinary frequency could mean that the baby's head has descended further into the pelvis. This can indicate that labor is approaching, as the baby is getting into position for birth. It is important for the nurse to provide this information to ease the patient's concerns and help her understand the potential significance of these symptoms at 40 weeks' gestation.
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The nurse is caring for a 14-year-old boy with a growth hormone deficiency. Which action best reflects using the nursing process to provide quality care to children and their families?
- A. Reviewing the effectiveness of interventions
- B. Questioning the facility standards for care
- C. Earning continuing education credits
- D. Ensuring reasonable costs for care provided
Correct Answer: A
Rationale: The nursing process is used to care for the child and family during health promotion, maintenance, restoration, and rehabilitation. Reviewing the effectiveness of interventions is related to outcome evaluation in the nursing process.
The nurse is teaching a prenatal class about fetal development. When does the heart begin to beat?
- A. At 4 weeks' gestation.
- B. At 8 weeks' gestation.
- C. At 12 weeks' gestation.
- D. At 16 weeks' gestation.
Correct Answer: A
Rationale: The fetal heart begins beating as early as 4 weeks' gestation, signaling early circulatory development.
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
- A. Moderate lochia rubra
- B. Fundus three fingerbreadths above the umbilicus
- C. Moderate swelling of the labia
- D. Blood pressure 130/84 mm Hg
Correct Answer: B
Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.
The nurse is caring for a 2-week-old girl with a metabolic disorder. Which activity would deviate from the characteristics of family-centered care?
- A. Softening unpleasant information or prognoses
- B. Evaluating and changing the nursing plan of care
- C. Collaborating with the child and family as equals
- D. Showing respect for the family's beliefs and wishes
Correct Answer: A
Rationale: Family-centered care requires that the nurse provide open and honest information to the child and family. It is inappropriate to soften unpleasant information or prognoses.
What is an appropriate response to a 16-year-old woman seeking emergency contraception after unprotected intercourse?
- A. You can walk into your local pharmacy and buy Plan B (levonorgestrel).
- B. I am sorry but because of your age I am unable to assist you.
- C. The emergency room doctor can prescribe high-dose birth control pills (BCP) for you.
- D. The nurse's response is dependent upon which state he or she is practicing in.
Correct Answer: A
Rationale: Plan B is available over-the-counter for individuals of all ages.