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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 48-year-old female patient presents to the OB/GYN clinic for her annual examination. She states that she has had the following symptoms: mood swings, irregular menstrual cycles, forgetfulness, food cravings, and a decrease in libido. Which of the following does the nurse suspect the patient is experiencing?
- A. Menopause
- B. Perimenopause
- C. Postmenopause
- D. Pregnancy
Correct Answer: B
Rationale: Perimenopause is the transitional period leading to menopause that usually begins in a woman's 40s but can start earlier. During this phase, women may experience symptoms such as mood swings, irregular menstrual cycles, forgetfulness, food cravings, and a decrease in libido, as described by the patient in this case. These symptoms are caused by hormonal fluctuations as the ovaries start to produce less estrogen in preparation for menopause. Menopause occurs when a woman has not had a menstrual period for 12 consecutive months. Postmenopause, on the other hand, refers to the stage after menopause, where menopausal symptoms have generally subsided. The symptoms described by the patient are more indicative of the perimenopausal stage rather than pregnancy, as they are typical signs of hormonal changes associated with the menopausal transition.
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.
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.
The nurse is providing postoperative care to a patient who underwent a total abdominal hysterectomy 12 hours ago. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Assist the patient with ambulation.
- B. Maintain the Foley catheter for 48 to 72 hours postoperatively.
- C. Monitor intake and output and characteristics of urin
- D. urinary tract infection
Correct Answer: A
Rationale: A. Assist the patient with ambulation: Encouraging early ambulation after surgery helps prevent complications such as blood clots, pneumonia, and pressure ulcers. It also promotes circulation and aids in the recovery process.
A patient arrives to the clinic 2 hours late for her prenatal appointment. This is the third time she has been late. What is the nurse’s best action in response to this patient’s tardiness?
- A. Ask the patient if she has a way to tell the time.
- B. Ask the patient if she is deliberately being late for her appointments.
- C. Determine if the patient wants this baby and if this is her way of acting out.
- D. Determine if the patient arrives after the start time for other types of appointments.
Correct Answer: C
Rationale: The nurse's best action in response to the patient's tardiness is to determine if the patient wants this baby and if this is her way of acting out. Tardiness to prenatal appointments can sometimes indicate underlying issues such as ambivalence towards the pregnancy or emotional distress. By addressing the patient's motivation for being consistently late, the nurse can better understand and support her needs. This approach allows for a more patient-centered and compassionate response, aiming to address any possible concerns or challenges the patient may be facing.