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What is the gravida and para for a patient who delivered triplets 2 years ago and is now pregnant again?
- A. 2, 3
- B. 1, 2
- C. 2, 1
- D. 1, 3
Correct Answer: C
Rationale: The correct answer is C: 2, 1. Gravida refers to the total number of pregnancies, including the current one. The patient delivered triplets 2 years ago, so she is currently pregnant again, making her total pregnancies 2. Para refers to the number of deliveries after 20 weeks of gestation, regardless of the number of fetuses. Since she delivered triplets 2 years ago, she had 1 delivery after 20 weeks of gestation, making her para 1. Choices A, B, and D are incorrect as they do not accurately reflect the patient's obstetric history based on the information provided.
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A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: Step 1: The baseline fetal heart rate is 135 bpm, which is within the normal range of 110-160 bpm.
Step 2: The four nonepisodic patterns of fetal heart rate reaching 160 bpm for 20-25 seconds each indicate accelerations, a positive sign.
Step 3: A reactive NST requires at least two accelerations of the fetal heart rate within a 20-minute window, which this scenario meets.
Step 4: Therefore, the nurse will record these findings as NST reactive, reassuring because the fetal heart rate responded appropriately to stimuli.
Summary of Other Choices:
A: NST positive, nonreassuring - Inaccurate, as the findings indicate a reassuring response.
B: NST negative, reassuring - Incorrect, as the test results are actually reactive, not negative.
D: NST nonreactive, nonreassuring - Wrong, as the test is reactive and reassuring, not nonreactive and nonreassuring.
When caring for a woman whom a nurse suspects is being abused by her partner, the nurse should do which of the following?
- A. Ask the client directly about how she sustained her injuries.
- B. Counsel the client on how her behavior probably provoked the attack.
- C. Inform the client that the police must arrest her partner.
- D. Give the client a pamphlet with the names of matrimonial attorneys.
Correct Answer: A
Rationale: Directly asking about injuries helps assess the situation and provide appropriate support and resources.
The nurse receives a phone call from a patient concerned about the results of the laboratory tests obtained at the first prenatal visit 10 days ago. What is the nurse's next action?
- A. ask the patient if they have checked their electronic chart
- B. inform the patient they will need to wait until the next office visit for the results
- C. provide the patient with the results of the tests
- D. verify the identification of the patient
Correct Answer: D
Rationale: The correct answer is D: verify the identification of the patient. This is crucial to ensure patient safety and confidentiality. By verifying the patient's identity, the nurse can confirm they are providing the correct information to the right person, preventing potential errors or breaches of confidentiality. Asking about the electronic chart (A) is unnecessary if the identity is not confirmed. Informing the patient to wait (B) does not address the immediate concern. Providing results (C) without proper identification can lead to miscommunication. Hence, verifying the patient's identification is the first step to address the patient's concerns effectively.
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. It would be appropriate for the nurse to delegate which of the following actions to the assistant?
- A. Admission assessment on a newly delivered baby.
- B. Patient teaching of a neonatal sponge bath.
- C. Placement of a bag on a baby for urine collection.
- D. Hourly neonatal blood glucose assessments.
Correct Answer: C
Rationale: CNAs can perform tasks such as placing a urine collection bag, which does not require advanced assessment or teaching skills. Admission assessments and blood glucose monitoring require the expertise of an RN.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.