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Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
- A. Risk for anxiety related to upcoming birth
- B. Risk for imbalanced nutrition related to NPO status
- C. Risk for altered family processes related to new addition to the family
- D. Risk for injury (maternal) related to altered sensations and positional or physical
changes
Correct Answer: D
Rationale: The priority nursing diagnosis for a patient in active labor should focus on ensuring the safety and well-being of the mother and the baby. "Risk for injury (maternal) related to altered sensations and positional or physical changes" is the most crucial diagnosis in this scenario as it directly addresses potential risks and complications that may occur during labor and delivery. This nursing diagnosis includes considerations for the physical changes the mother undergoes during labor, such as altered sensations and positioning, which can increase the risk of injury. By identifying and addressing this risk promptly, the nurse can help prevent potential harm to the mother and ensure a safe delivery process.
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A nurse is caring for a pregnant patient who asks when she should be tested for GBS. What does the nurse tell the patient?
- A. 34–35 weeks
- B. 36–37 weeks
- C. 38–39 weeks
- D. 39–40 weeks
Correct Answer: B
Rationale: The nurse should inform the pregnant patient that Group B Streptococcus (GBS) testing is typically done between 36 and 37 weeks of pregnancy. Testing at this time allows for optimal identification of GBS colonization during childbirth. It is important to test at this stage to determine the presence of GBS in the birth canal, as GBS can be passed to the newborn during delivery, which may lead to serious infections. Testing later in pregnancy increases the likelihood of obtaining accurate results closer to the due date, enabling appropriate management to be implemented to reduce the risk of transmission to the newborn.
The nurse is formulating a nursing care plan for a postpartum patient. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply.)
- A. Using a standardized postpartum care plan
- B. Determining priorities for each diagnosis written
- C. Writing interventions from a nursing diagnosis book
- D. Reflecting and suspending judgment when writing the care plan
Correct Answer: B
Rationale: B. Determining priorities for each diagnosis written: Prioritizing nursing diagnoses based on the patient's needs and condition requires critical thinking skills. The nurse must be able to identify the most urgent issues to address first in the care plan.
Which goal is most appropriate for the collaborative problem of wound infection?
- A. The patient will not exhibit further signs of infection.
- B. Maintain the patient’s fluid intake at 1000 mL/8 hour.
- C. The patient will have a temperature of 98.6F within 2 days.
- D. Monitor the patient to detect therapeutic response to antibiotic therapy.
Correct Answer: A
Rationale: The most appropriate goal for the collaborative problem of wound infection is "The patient will not exhibit further signs of infection." This goal directly addresses the issue of controlling and resolving the infection within the wound, leading to the overall improvement in the patient's condition. By ensuring that the patient does not exhibit further signs of infection, healthcare providers can monitor the effectiveness of treatment interventions and prevent any complications that may arise from the infection spreading or worsening. In contrast, options B, C, and D are not directly related to addressing the wound infection itself, making them less appropriate goals for this specific problem.
Which patient will most likely seek prenatal care?
- A. A 15-year-old patient who tells her friends, “I just don’t believe that I am pregnant”
- B. A 28-year-old who is in her second pregnancy and abuses drugs and alcohol
- C. A 20-year-old who is in her first pregnancy and has access to a free prenatal clinic
- D. A 30-year-old who is in her fifth pregnancy and delivered her last infant at home with the help of her mother and sister
Correct Answer: C
Rationale: The patient in option C is the most likely to seek prenatal care. This is because she is in her first pregnancy, indicating that she may be more inclined to seek medical guidance and support for the first time experience of pregnancy. Furthermore, the fact that she has access to a free prenatal clinic suggests that she has the resources and opportunity to obtain proper prenatal care, which can significantly benefit her and her baby's health. In contrast, the patients in the other options either demonstrate risky behaviors (such as drug and alcohol abuse in option B) or have previously given birth without professional medical assistance (as indicated in option D), which may indicate lower likelihood of seeking prenatal care. The patient in option A also demonstrates denial of pregnancy, which could delay seeking necessary prenatal care.
Which statement best describes the advantage of a labor, birth, recovery, and postpartum (LDRP) room?
- A. The family is in a familiar environment.
- B. They are less expensive than traditional hospital rooms.
- C. The infant is removed to the nursery to allow the mother to rest.
- D. The woman’s support system is encouraged to stay until discharge.
Correct Answer: A
Rationale: One of the advantages of a labor, birth, recovery, and postpartum (LDRP) room is that the family is in a familiar environment. LDRP rooms are designed to provide a comfortable setting where the mother, baby, and family can stay together throughout the entire childbirth process. This environment allows for better continuity of care, enhances bonding between the baby and the family, and helps reduce stress and anxiety often associated with being in an unfamiliar hospital setting. Being in a familiar environment can also promote a sense of security and control for the mother, which can positively impact her overall birthing experience.