The clinic nurse is performing phone triage on pregnant patients. Which patient will the nurse refer to the hospital for immediate evaluation?

The patient who is 11 weeks pregnant and nauseous, tired, and sleepy most of the day.

The patient who is 30 weeks pregnant complained of "blurred vision and seeing spots."

The patient who is 40 weeks pregnant and has to urinate every 2 hours.

The patient who is 37 weeks pregnant and has 4 to 5 contractions in an hour.

Answer and Explanation

The Correct Answer is B

Choice A reason: While nausea, tiredness, and sleepiness are common during the first trimester of pregnancy, they are typically not signs of an immediate emergency. This patient does not exhibit any alarming symptoms that would require immediate hospital referral.

Choice B reason: Blurred vision and seeing spots during pregnancy can be symptoms of preeclampsia, a potentially dangerous condition characterized by high blood pressure. Preeclampsia can pose serious health risks to both the mother and the baby and requires immediate medical attention.

Choice C reason: Frequent urination is a common symptom in the later stages of pregnancy due to the pressure the growing baby exerts on the bladder. This symptom alone does not indicate an immediate need for hospital evaluation.

Choice D reason: Having 4 to 5 contractions in an hour at 37 weeks of pregnancy can be a sign of early labor. However, unless the contractions are persistent and intensifying, this may not necessitate an immediate hospital referral. The nurse would likely advise the patient to monitor the contractions and come in if they continue or become stronger.

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Correct Answer is A

Explanation

Choice A reason: Pathologic jaundice is an abnormal condition that typically appears within the first 24 hours of life. It often indicates an underlying health problem and requires prompt medical evaluation and intervention.

Choice B reason: Both pathologic and physiologic jaundice are not treated with exchange transfusions of maternal O-negative blood. Exchange transfusions are only considered in severe cases of jaundice, typically for pathologic jaundice when other treatments are ineffective.

Choice C reason: Physiologic jaundice is a common and usually harmless condition that occurs in many newborns, peaking around the second or third day of life. It does not result in kernicterus, a rare but severe form of brain damage caused by very high levels of bilirubin. Pathologic jaundice, if untreated, may lead to kernicterus.

Choice D reason: Physiologic jaundice generally does not require transfer to the neonatal intensive care unit. It is usually managed with simple interventions, such as phototherapy, and often resolves on its own as the newborn's liver matures and becomes more efficient at processing bilirubin.

A. Oral suspension. B. Intravenous infusion. C. Subcutaneous injection. D. Intramuscular injection.

Correct Answer is D

Explanation

Choice A reason: Oral suspension is not an appropriate method for administering botulinum toxin. This medication is not effective when taken orally and needs to be administered directly into the muscle to address spasticity.

Choice B reason: Intravenous infusion is also not the appropriate method for administering botulinum toxin. The medication is intended to act locally at the site of injection to reduce muscle spasticity, and intravenous administration would not achieve the desired localized effect.

Choice C reason: Subcutaneous injection is not the correct method for administering botulinum toxin. This medication needs to be injected directly into the muscle to have a therapeutic effect on muscle spasticity.

Choice D reason: Intramuscular injection is the correct method for administering botulinum toxin. The medication works by blocking the release of acetylcholine at the neuromuscular junction, thereby reducing muscle spasticity. Administering it directly into the muscle ensures that the medication reaches its target and provides the desired therapeutic effect.

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The clinic nurse is performing phone triage on pregnant patients. Which patient will the nurse refer to the hospital for immediate evaluation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching to a postpartum patient. Which information will the nurse include when teaching the parent about the difference between pathologic and physiologic jaundice?

Correct Answer is A

Explanation

The nurse is preparing to administer botulinum toxin to a child with spastic cerebral palsy. How will the nurse administer this medication?

Correct Answer is D

Explanation

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