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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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Which suggestion is most helpful for the pregnant patient who is experiencing heartburn?
- A. Drink plenty of fluids at bedtime.
- B. Eat only three meals a day so the stomach is empty between meals.
- C. Drink coffee or orange juice immediately on arising in the morning.
- D. Use Tums or Rolaids to obtain relief, as directed by the health care provider.
Correct Answer: D
Rationale: The correct answer is D because Tums or Rolaids are safe antacids commonly recommended for heartburn during pregnancy. They help neutralize stomach acid and provide relief. Choice A is incorrect as drinking fluids before bedtime can aggravate heartburn. Choice B is incorrect because it's important to eat small, frequent meals to prevent heartburn. Choice C is incorrect as coffee and orange juice can trigger heartburn due to their acidity. Overall, using antacids under healthcare provider guidance is the best option for managing heartburn during pregnancy.
At the first prenatal visit, the patient informs the nurse that the first day of her last menstrual period (LMP) was February 18, 2024. Using Naegle's Rule, calculate the patient's EDD.
- A. 11-Nov-24
- B. 11-Nov-25
- C. 25-Nov-24
- D. 25-Nov-25
Correct Answer: C
Rationale: The correct answer is C: 25-Nov-24. Naegle's Rule is to add 7 days to the first day of the last menstrual period (LMP), then subtract 3 months, and finally add 1 year. In this case, LMP was February 18, 2024. Adding 7 days gives February 25, 2024. Subtracting 3 months gives November 25, 2024. Adding 1 year gives the estimated due date (EDD) of November 25, 2024. Choices A, B, and D are incorrect because they do not follow the correct calculation steps of Naegle's Rule.
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.
The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?
- A. Complaints of severe back pain.
- B. Rapid descent and effacement.
- C. Irregular and hypotonic contractions.
- D. Rectal pressure with bloody show.
Correct Answer: A
Rationale: The LOP (left occiput posterior) position often causes back pain due to the fetal head pressing against the mother’s sacrum.
A nurse sees an overweight woman looking at the babies through the nursery window. The woman asks the nurse when the babies go to their mothers for feedings and about the location of the nearest stairwell. Which of the following replies by the nurse is most appropriate at this time?
- A. The babies go to their mothers whenever they seem hungry.'
- B. Please let me escort you to the mother’s room you are here to visit.'
- C. The babies are in the mothers’ rooms for the majority of the day.'
- D. Most of our visitors prefer to use the elevator to return to the lobby.'
Correct Answer: B
Rationale: Escorting the visitor ensures she reaches the correct destination and maintains security in the nursery area.