A 25-year-old female, with no prenatal care, is brought into your LAD unit by ambulance with vagina bleeding Based upon what she thinks in her LMP, she is suspected of being 26 weeks of gestation. The patients combative, yelling at staff, and refuses to change into a patient gown. The nurse suspects possible drug use and history of psychological disorders. She has had no prenatal care. What is not an appropriate nursing action at this time?

Ensure that the patient's external environment is free from excessive stimuli.

Ask her what drugs she has taken and when was the last time.

Administer prescribed sedatives.

Perform a vaginal exam.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Ensuring a calm environment by minimizing excessive stimuli is important for the safety and well-being of the patient.

B. Asking about drug use is essential to understand potential risks and provide appropriate care.

C. Administering sedatives to a combative patient without assessing the situation further could be dangerous. It could harm the patient and fetus, especially if drug use or psychological disorders are suspected.

D. Performing a vaginal exam is necessary to assess bleeding and determine if there are any signs of preterm labor or other complications.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Sleeping for 6 consecutive hours is not ideal for a 6-day-old newborn, as they should be feeding every 2-3 hours to maintain hydration and adequate nutrition.

B. Breastfeeding every 4 to 5 hours for 5 minutes per breast is too infrequent and brief for a newborn who should be feeding more often and for longer durations.

C. Six to eight wet diapers per day is a good indicator that the newborn is getting enough breast milk, as this indicates appropriate hydration and feeding.

D. Gaining 1 to 2 ounces the first week is below the expected rate of weight gain, which should typically be about 5-7 ounces per week for a newborn.

A. "The high blood volume and Wharton's jelly content of the umbilical cord prevent compression of the cord." B. “The umbilical cord normally contains two veins and one artery." C. "The fetal heart starts to beat at 4 weeks." D. “8 to 12 weeks heart rate can be heard with a doppler."

Correct Answer is B

Explanation

A. The high blood volume and Wharton's jelly content in the umbilical cord help protect it from compression.

B. The umbilical cord normally contains two arteries and one vein. A statement suggesting two veins is incorrect and indicates a need for additional teaching.

C. The fetal heart starts to beat around 4 weeks of gestation.

D. A Doppler can detect fetal heartbeats as early as 8-12 weeks.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartum woman telephones about her 6 day old infant. She is not scheduled for a weight check until the infant is 10 days old and she is worried about whether the baby is getting enough mi Which of the following statements demonstrate effective breastfeeding for her newborn?

Correct Answer is C

Explanation

The nurse educator is preparing an educational workshop on fetal development. Which statement from a patient would indicate they need additional teaching or information?

Correct Answer is B

Explanation

You are teaching a class on STDs to a group of women. Which of the following responses indicates teaching was successful.

At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).

When teaching parents about mandatory newborn screening, which of the following is the most important rationale for why the newborn screening test is given (often called PKU because this was the test mandated)?

A patient comes to the clinic to be tested for Gonorrhea. Which of the following is true of this particular STD? Select all that apply

The nurse is evaluating the effectiveness of breastfeeding of a neonate prior to discharge. Which of the following would be included in the LATCH score? (Select all that apply).

A 26 week G3 P2 has premature rupture of membranes. Which of the following orders would the nurse question?

Place cursor where you are most likely to see Mongolian spots?