OB and Mental 1 Flashcards
38 weeks’ gestation patient. Upon vaginal examination, the nurse observe a segment of the umbilical cord extending out of the labia. Which nursing action is appropriate? SATA
a) Assist the client to lay on her left side
b) Encourage the client to ambulate
c) Help the client pull her knees to her chest
d) Perform frequent Leopold maneuvers
e) If the knee chest is not feasible, place the client in Trendelenburg position
c,e
A pregnant client who requires a cervical cerclage procedure. Which client statement indicates a need for additional instruction from the nurse? SATA
a) I need to plan on having the cerclage removed toward the end of my second trimester.
b) I will need to be placed on bed rest after the cervical cerclage to decrease premature dilation.
c) “I should expect some pressure in my pelvis after the procedure.
d) “If I have any low back pain, I will contact my doctor.
e) This procedure is done to assess for preterm labor
a,b,c,e
a) typically removed around 37 weeks’ gestation
second will be 13-27 wks
b) Bed rest is not required
c) This procedure should not produce feelings of fullness in the pelvis
e) The procedure is not done to assess preterm labor but to halt premature dilation of the cervix
PT with anorexia nervosa and is significantly malnourished. The client is refusing to consume food by mouth.
Which dietary order should the nurse anticipate for this client?
a) Soft diet
b) Liquid diet
c) Enteral nutrition
d) Total parenteral nutrition
c
A nasogastric tube can be inserted for the administration of formula that is rich in both calories and protein.
d
The use of TPN is more invasive that enteral nutrition by tube
The nurse is caring for a client who is prescribed disulfiram for alcohol use disorder.
What nursing action(s) are appropriate for this client?
SATA
a) Teach the client to avoid common over-the-counter (OTC) cough medications.
b) Instruct the client that alcohol consumption while on the prescribe medication produces unwanted side effects.
c) Teach the client that, if a dose of disulfiram is missed, take an extra dose as soon as possible.
d) Teach the client to abstain from alcohol for two weeks after the medication is discontinued.
e) Inform the client that certain foods, such as vinegar and some sauces should be avoided while on this medication.
a,b,d,e
Avoid the consumption of any alcohol, including sources of hidden alcohol which may include cold and cough medications, mouthwashes, aftershaves, colognes
and certain foods
Use of crutches for walking. Which finding noted by the nurse illustrates the proper use of crutches? SATA
a) The client flexes the elbows approximately 30 degrees when using the crutches.
b) The client advances the crutches and affected leg at the same time in a 3-point gait.
c) The client supports the body weight solely using the axillae.
d) The client’s weight is on the crutches and supported by the hands and arms.
a,b,d
Body weight is supported by the arms and hands and not the underarm area; and a 20 to 30 degree of flexion at the elbow.
A 3-point gait is used for clients who cannot bear any weight as it allows for injured extremity and crutches are moved together at the same time.
The nurse is caring for a neonate who requires respiratory resuscitation.
In which position should the client’s head be placed?
a) The newborn is placed in a side-lying position.
b) The newborn’s head is placed in a neutral position.
b
a
A side-lying position may be appropriate for recovery; however, this position will not allow respiratory resuscitation efforts to effectively oxygenate the newborn.
The nurse provides care for a laboring client with hypertonic uterine dysfunction. Which is the priority action by the nurse?
a) Preparing for an amniotomy
b) Providing pain relief measures
c) Monitoring the oxytocin infusion
d) Encouraging frequent ambulation
b
A male client who has chickenpox with open wounds draining pus. Which intervention should the nurse include in the plan of care? SATA
a) Before entering the client’s room, don a gown, gloves and N95 respirator mask
b) Ensure that the client is placed in a negative pressure, private room
c) Continue to implement airborne precautions once lesions are dry and scabbed over.
d) Provide a disposable thermometer and stethoscope to stay in the client’s room.
Chickenpox=varicella
a,b,d
Airborne precautions are a specific type of transmission-based precautions.
Once the lesions are crusted over and dry, varicella is no longer considered contagious; therefore, airborne precautions are no longer necessary.
Which client in the first 3 months of pregnancy requires priority action by the nurse?
a) A client, who is pregnant for the first time, reports brown discoloration on her face.
b) A client who has not urinated for more than 3 hours.
c) A client experiencing scapular and abdominal pain after diagnosis of an ectopic pregnancy.
c
s/s of rupture includes abdominal firmness; abdominal pain; and pain that radiates to the back and shoulder
a) normal
b) need furture aseesmemt, but not priority
Which client is at the highest risk for developing a pressure injury while hospitalized?
a) A client with paraplegia, pneumonia, temperature of 101.5 F (38.6 C), and white blood cell (WBC) count of 12,000/mm3 (12x109 L).
b) A client who is receiving a dopamine infusion, has a documented weight loss of 15 lbs (6.2 kg) in 21 days, a history of human immunodeficiency virus (HIV), and a critically low prealbumin level.
c) A client who is 5 days post appendectomy, has an indwelling urinary catheter, and a hemoglobin of 12 g/dL (120 g/L).
d) A client who is 1 day postoperative for a knee replacement, with hemoglobin of 10 g/dL (100 g/L), temperature of 99 F (37.2 C) and a white blood cell (WBC) count of 12,000/ mm3 (12 x109 L).
b
4 risk factors
comorbidity -HIV
poor perfusion- dopamine infusion
poor nutrition-low serum prealbumin
weight loss
a)
2 risk factors
comorbidity-paraplegia
infection
c)
2 risk factors
medical device-cathter
comorbidity-appendectomy
Advanced age; Altered levels of consciousness (LOC); Comorbidities (e.g., HIV); Immobility; Incontinence; Infection; Use of medical devices; Poor oxygenation and perfusion (e.g., dopamine infusion); Poor nutrition (e.g., low serum prealbumin level); Unintentional weight loss.
The nurse is caring for a client exhibiting behaviors related to an untreated psychiatric disorder.
Which assessment finding would necessitate mandatory placement of a client in the psychiatric inpatient facility? SATA
a) Threats to harm self or others on multiple occasions.
b) Extensive family history of bipolar disorder left untreated.
c) The client appears malnourished due to the refusal to eat or drink for one week.
d) A client who states over and over, “I must hide from them or they’ll get me.”
a,c,d
Mandatory placement into a psychiatric facility would be needed if the client’s judgment is severely impaired.
d) due to hallucinations or potential substance use disorder. Additionally, this client is likely at risk for harm to self or others
Is a bluish discoloration on a newborn’s gluteus maximus normal?
That is a mongolian spot
gluteus maximus=around butt
An adolescent client who is diagnosed with a fear of school and has missed an excessive amount of classes.
What is an appropriate nursing action(s)?
a) Recommend the parent keep the client out of school for at least 3 months.
b) Explain to the parent that the child should be medicated before returning to school.
c) Have the parent promptly return the child to school, starting gradually with half days.
d) Have the parent inquire about allowing the child to finish the school year at home
c
Supportive interventions such as insisting on school attendance will help the child make a faster adjustment. A gradual approach decreases the child’s sensitization to the classroom.
a-Allowing the child to avoid school reinforces the behavior;
b-Medication interventions for school phobia are not considered a therapeutic
Couple asks, “Will we be able to find out the gender of our baby at 16 weeks’of pregnancy?” Which response by the nurse is accurate?
a) Depending on your baby’s position, the genitalia may be observed at that point in pregnancy
b) External structures, such as genitalia, are not formed at 16wks
c) Specific gender characteristics are not identifiable until 20Wks
d) The gender of the fetus will be determined when ballottement is felt
a
The gender of the fetus can be determined by ultrasound as early as 14 weeks’ gestation
d
a technique used to diagnose pregnancy by feeling the return impact of the displaced fetus after a sharp tap with the fingers on the uterus.
a) What is parenteral medication?
b) Is 18 gauge thicker than 25 gauge?
a) drugs given by routes other than the digestive tract
intradermal, ID
subcutaneous, SUBQ
intramuscular, IM
intravenous IV.
b) Yes, smaller number is thicker
like insuline use 29-32 gauge
The nurse preceptor is observing a newly hired nurse prepare a parenteral medication for administration. Which action by the newly hired nurse demonstrates to the nurse preceptor proper technique?
a) Uses a 90-degree angle of insertion to administer insulin into the lower abdomen of a client who is overweight
b) Selects a 1 inch, 18-gauge needle to administer a subcutaneous injection.
c) Places a client in a prone position for an intramuscular (IM) deltoid injection
d) Uses a filter needle to withdraw medication from a glass ampule then changes the needle prior to injection.
a,d
b) Subcutaneous injections usually require a 25 to 30 gauge needle with lengths from 1/2 to 5/8 inches
c) A supine, not prone
psychosomatic disorder?
a condition that causes physical symptoms due to psychological stress
usually lacking a medical explanation
A client with psychosomatic disorder. The client reports a headache with nausea, rating the pain as 9 out of 10 on a numeric pain scale.
What is the appropriate nursing action?
a) Discuss strategies to decrease stress and alleviate the current symptoms
b) Redirect the conversation to unrelated, general topics of conversation.
b
The primary nursing intervention when providing care for clients with this diagnosis is to focus on minimizing indirect benefits and developing client insight.the appropriate action by the nurse is to redirect the client to an unrelated, general topic of conversation.
Which mind-body intervention should the nurse consider implementing for a laboring client who does not wish to receive medication for the treatment of the pain?
a) Deep abdominal breathing
b) Therapeutic touch
c) Hydrotherapy
a
