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Which laboratory result would be a cause for concern if exhibited by a patient at her first prenatal visit during the second month of her pregnancy?
- A. Rubella titer, 1:6
- B. Platelets, 300,000/mm3
- C. White blood cell count, 6000/mm3
- D. Hematocrit 38%, hemoglobin 13 g/dL
Correct Answer: A
Rationale: The correct answer is A: Rubella titer, 1:6. A low rubella titer indicates susceptibility to rubella infection, which can be harmful during pregnancy. Rubella can lead to birth defects or miscarriage. Platelets, WBC count, and hematocrit/hemoglobin levels are within normal range and not typically concerning during the early stages of pregnancy.
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An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient?
- A. Hospice
- B. Respite care
- C. Assisted living
- D. Skilled nursing
Correct Answer: D
Rationale: An intermediate care or skilled nursing facility offers skilled care from a licensed nursing staff.
The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
- A. During labor, when she can no longer talk through contractions
- B. During the first stage of labor, when the contractions are 3 to 4 minutes apart
- C. Between contractions, during the transitional phase of the first stage of labor
- D. Between her efforts to push to facilitate relaxation between contractions
Correct Answer: A
Rationale: The correct answer is A: During labor, when she can no longer talk through contractions. This is the best time to encourage slow, deep chest breathing as it helps the laboring patient stay calm, focused, and manage pain effectively during the intense active phase of labor. When a woman reaches the point where she can no longer talk through contractions, it indicates that she is in the active phase of labor and may benefit from slow, deep breathing to help cope with the intensity of contractions.
Explanation for why other choices are incorrect:
B: During the first stage of labor, when the contractions are 3 to 4 minutes apart - Contractions being 3 to 4 minutes apart may not necessarily indicate the active phase of labor requiring slow, deep breathing.
C: Between contractions, during the transitional phase of the first stage of labor - Transitional phase contractions are typically intense and close together, making it less ideal for relaxation breathing between contractions.
D: Between her efforts
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 pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient's plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: The correct answer is B: Refer to the physician for additional testing. When a triple-screen test is positive in a pregnant patient, it indicates an increased risk of certain conditions such as neural tube defects or chromosomal abnormalities. Therefore, the appropriate course of action is to refer the patient to a physician for further diagnostic testing, such as amniocentesis or ultrasound, to confirm or rule out these conditions.
Choice A is incorrect because a positive result on a triple-screen test does not indicate that results are normal; it suggests the need for further investigation. Choice C is incorrect because validating the results with the lab facility does not address the need for additional diagnostic testing. Choice D is incorrect because waiting 2 weeks to repeat the test and returning for a regular prenatal visit may delay necessary interventions or treatment for the patient.
A pregnant patient's biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse's most appropriate response?
- A. The test results are within normal limits.'
- B. Immediate birth by cesarean birth is being considered.'
- C. Further testing will be performed to determine the meaning of this score.'
- D. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.'
Correct Answer: A
Rationale: The correct answer is A: "The test results are within normal limits." A biophysical profile score of 8 is considered normal. A score of 8 out of 10 indicates that the fetus is likely healthy and does not require immediate delivery. The other choices are incorrect because immediate birth by cesarean section is not warranted for a score of 8, further testing is not necessary as the score is normal, and there is no need for an obstetric specialist to evaluate the results urgently. The most appropriate response reassures the patient that the results are normal, providing comfort and clarity.