Nokea
Which step of the nursing process is being used when the nurse decides whether an ethical dilemma exists?
- A. Analysis
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Deciding whether an ethical dilemma exists involves analyzing collected data to determine if conflicting values or principles are present.
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In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: The planning phase involves determining appropriate interventions for identified problems during assessment.
A primigravida at 39-weeks gestation is admitted to the labor and delivery unit in active labor. She is given an epidural anesthetic. Her blood pressure drops to 90/50 mm Hg, and the fetal heart rate shows late decelerations. What is the most likely cause of these findings?
- A. Maternal hypotension.
- B. Uteroplacental insufficiency.
- C. Fetal distress.
- D. Amniotic fluid embolism.
Correct Answer: A
Rationale: Maternal hypotension following epidural anesthesia can lead to decreased placental perfusion, causing late decelerations in the fetal heart rate.
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
- A. Complete a sterile vaginal exam
- B. Take maternal temperature every 2 hours
- C. Prepare for an immediate cesarean birth
- D. Obtain sterile suction equipment
Correct Answer: A
Rationale: A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.
Which guidance related to a healthy diet during pregnancy will the nurse provide to a patient in her 1st trimester?
- A. Every day you need to have at least 6 ounces of protein from sources such as meat, fish, eggs, beans, nuts, soybean products, and tofu.'
- B. High-dose vitamin A supplements will promote optimal vision while preventing a common cause of blindness in neonates.'
- C. Meals such as sushi with a cold deli salad made with raw sprouts combine high-fiber foods with protein sources to meet multiple nutritional needs.'
- D. Vitamin and mineral supplements can meet your nutrient needs if you have inadequate intake because of nausea or a sensation of fullness.'
Correct Answer: A
Rationale: Step 1: During pregnancy, protein is essential for the growth and development of the fetus, making option A correct.
Step 2: The other options are incorrect due to potential risks. High-dose vitamin A (Option B) can be harmful to the fetus.
Step 3: Consuming raw sprouts (Option C) poses a risk of foodborne illness, which can be dangerous during pregnancy.
Step 4: Relying solely on supplements (Option D) is not recommended as they may not provide all the necessary nutrients found in whole foods.
In summary, option A is correct as it emphasizes the importance of protein intake during pregnancy, while the other options pose potential risks or limitations in meeting nutritional needs.
A pregnant patient would like to know which foods, other than dairy products, contain the most calcium. Which food group would the nurse recommend?
- A. Legumes
- B. Lean meat
- C. Whole grains
- D. Yellow vegetables
Correct Answer: A
Rationale: The correct answer is A: Legumes. Legumes such as chickpeas, lentils, and beans are rich sources of calcium. They provide a plant-based alternative for calcium intake. Legumes are also high in fiber, protein, and other essential nutrients beneficial for pregnancy. Lean meat (B) and yellow vegetables (D) are not significant sources of calcium. While whole grains (C) offer some calcium, they are not as high in calcium content as legumes. Therefore, for a pregnant patient looking to increase calcium intake without relying on dairy products, legumes are the most recommended food group.