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The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
- A. Repeat the test in 1 week so that results can be trended based on this baseline result.
- B. Contact the health care provider to discuss birth options for the patient.
- C. Send the patient out for a meal and repeat the test to confirm that the results are valid.
- D. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.
Correct Answer: B
Rationale: The correct answer is B because a positive contraction stress test (CST) indicates potential fetal distress, requiring immediate medical attention. Contacting the health care provider is necessary to discuss birth options for the patient, such as potential induction or cesarean section to prevent harm to the fetus.
A is incorrect because waiting another week could pose risks to the fetus if distress is already present. C is incorrect as sending the patient out for a meal and repeating the test is not a valid or necessary intervention. D is incorrect as a fetal kick count assessment does not address the immediate concerns raised by a positive CST result.
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When should the nurse begin discharge planning?
- A. When the patient is ready
- B. Close to the time of discharge
- C. Upon admission to the hospital
- D. After an order is written/prescribed
Correct Answer: C
Rationale: Discharge planning begins the moment a patient is admitted to a health care facility.
When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: The correct answer is C: 10 weeks. CVS is typically performed between 10-12 weeks of gestation. At this time, there is enough fetal tissue for sampling without significant risk to the pregnancy. Performing CVS earlier (options A, B) may result in insufficient tissue for accurate testing, while performing it later (option D) may increase the risk of procedure-related complications. Option C provides the optimal balance between ensuring accurate results and minimizing potential risks to the pregnancy.
A patient in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse provide regarding safe travel during pregnancy?
- A. Only travel by car during pregnancy.'
- B. Avoid use of the seat belt during the third trimester.'
- C. You can travel by plane until your 38th week of gestation.'
- D. If you are traveling by car stop to walk every 1 to 2 hours.'
Correct Answer: D
Rationale: The correct answer is D: "If you are traveling by car, stop to walk every 1 to 2 hours." This is the best advice because it promotes circulation and reduces the risk of blood clots during long car rides. Walking helps prevent stiffness and discomfort.
A: "Only travel by car during pregnancy" is incorrect because other modes of transportation can be safe as well.
B: "Avoid use of the seat belt during the third trimester" is incorrect as wearing a seat belt is crucial for the safety of both the mother and the baby in case of an accident.
C: "You can travel by plane until your 38th week of gestation" is incorrect as most airlines have restrictions on flying after 36 weeks due to the risk of preterm labor.
A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.)
- A. Empirical quality results
- B. Structural empowerment
- C. Transformational leadership
- D. Exemplary professional practice
Correct Answer: A
Rationale: The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. The five components are Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovation, and Improvements; and Empirical Quality Results.
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
- A. Determine if a metabolic disorder exists.
- B. Identify the sex of the fetus.
- C. Identify abnormal fetal cells.
- D. Determine fetal lung maturity.
Correct Answer: D
Rationale: The correct answer is D: Determine fetal lung maturity. At 34 weeks of gestation, assessing fetal lung maturity is crucial to determine if the baby's lungs are developed enough for safe delivery. Amniocentesis can provide amniotic fluid for testing lung maturity. Choice A is incorrect as metabolic disorders are not typically assessed through amniocentesis. Choice B is incorrect as determining fetal sex is not the primary purpose of amniocentesis at this gestational age. Choice C is incorrect as identifying abnormal fetal cells is not the main goal of amniocentesis in this scenario.