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A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.
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What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
- A. Determine if a metabolic disorder exists.
- B. Identify the sex of the fetus.
- C. Identify abnormal fetal cells.
- D. Determine fetal lung maturity.
Correct Answer: D
Rationale: The correct answer is D: Determine fetal lung maturity. At 34 weeks of gestation, assessing fetal lung maturity is crucial to determine if the baby's lungs are developed enough for safe delivery. Amniocentesis can provide amniotic fluid for testing lung maturity. Choice A is incorrect as metabolic disorders are not typically assessed through amniocentesis. Choice B is incorrect as determining fetal sex is not the primary purpose of amniocentesis at this gestational age. Choice C is incorrect as identifying abnormal fetal cells is not the main goal of amniocentesis in this scenario.
The nurse is caring for a 45-year-old client who is scheduled to have a chorionic villus sampling. Which information is most important for the nurse to obtain from the client before the procedure?
- A. NPO status
- B. Blood type and Rh
- C. Weeks of gestation
- D. Maternal bleeding disorders
Correct Answer: D
Rationale: The correct answer is D: Maternal bleeding disorders. This information is crucial before a chorionic villus sampling to assess the risk of excessive bleeding during the procedure due to potential clotting issues. Maternal bleeding disorders can increase the risk of complications during the procedure.
A: NPO status is not as critical for this procedure as it does not typically require fasting.
B: Blood type and Rh are important for other purposes but not specifically needed before a chorionic villus sampling.
C: Weeks of gestation is important for determining the timing of the procedure but does not directly impact the safety or success of the procedure.
A nurse is completing a minimum data set. Which area is the nurse working?
- A. Nursing center
- B. Psychiatric facility
- C. Rehabilitation center
- D. Adult day care center
Correct Answer: A
Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.
The nurse is discussing the purpose of the physical examination with a patient at the first prenatal visit. What information does the nurse include in the discussion?
- A. The physical exam helps to confirm the patient's current health.
- B. The physical exam determines nutritional risk factors.
- C. The physical exam confirms the diagnosis of STIs.
- D. The physical exam includes urinalysis.
Correct Answer: A
Rationale: The correct answer is A because the physical exam at the first prenatal visit aims to confirm the patient's current health status, assess baseline health indicators, and identify any potential risks or issues that may affect the pregnancy. This information is crucial for developing a personalized care plan for the patient and ensuring a healthy pregnancy outcome.
Choice B is incorrect because determining nutritional risk factors typically involves assessing dietary habits, weight, and specific nutrient deficiencies, which are not solely addressed through a physical exam.
Choice C is incorrect as confirming the diagnosis of STIs would require specific testing and not solely rely on a physical examination.
Choice D is incorrect because while urinalysis may be part of the physical exam, its primary purpose is not solely to include urinalysis but to comprehensively evaluate the patient's overall health.