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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: The Diphtheria, Tetanus, and Pertussis (DTaP) vaccine is recommended for infants at 2, 4, and 6 months of age. It helps protect against three serious bacterial infections: diphtheria, tetanus, and pertussis.

Choice B reason: The Hepatitis B vaccine is usually administered at birth, 1-2 months, and 6-18 months. The 4-month visit may include this vaccine if it is part of the catch-up schedule or combined with other vaccines.

Choice C reason: The Inactivated Polio Vaccine (IPV) is given at 2, 4, and 6-18 months of age to protect against poliovirus, which can cause paralysis and other severe health issues.

Choice D reason: The Pneumococcal 13 Vaccine (PCV13) protects against 13 types of pneumococcal bacteria, which can cause serious infections like pneumonia, meningitis, and sepsis. It is typically given at 2, 4, and 6 months of age.

Choice E reason: The Haemophilus Influenzae type B (Hib) vaccine is administered at 2, 4, and 6 months of age to protect against infections caused by Hib bacteria, such as meningitis, pneumonia, and epiglottitis.

A. Vaginal delivery after 12 hours of Labor B. Primiparity delivered at 10 cm dilation C. Manual extraction of the placenta

Correct Answer is C

Explanation

Choice A reason: Vaginal delivery after 12 hours of Labor, while potentially exhausting for the mother, does not inherently place her at a higher risk for postpartum haemorrhage compared to other factors. Prolonged Labor can be associated with certain complications, but it is not the most direct indicator of increased haemorrhage risk in the postpartum period.

Choice B reason: Primiparity, or being a first-time mother, delivered at full dilation of 10 cm is a normal part of the childbirth process. While first-time mothers might experience longer Labor durations, this alone does not signify a higher risk for postpartum haemorrhage. Risk factors for haemorrhage typically involve conditions or interventions that impact the uterus's ability to contract effectively after birth.

Choice C reason: Manual extraction of the placenta is a significant risk factor for postpartum haemorrhage. When the placenta does not detach and deliver on its own, manual removal is necessary, which can cause trauma to the uterus and interfere with its ability to contract properly after delivery. The lack of effective uterine contraction can lead to increased bleeding, making this a higher risk scenario for postpartum haemorrhage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a 4-month-old child during a well visit. Which vaccines will the nurse prepare to administer for this child? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse is assessing postpartum patients. Which patient is at risk for postpartum haemorrhage?

Correct Answer is C

Explanation

The nurse is assessing a patient in Labor with the findings in the chart: Fatal heart rate 135 with early decelerations. What action will the nurse implement?

The nurse is educating a caregiver about infant feeding. Which statement by the caregiver demonstrates an understanding of the teaching?

A nurse is reviewing the assessment findings of a paediatric patient. Which finding will the nurse prioritize?

The nurse is teaching the student nurse about postpartum depression. Which strategy will the nurse include in the teaching?

A nurse is reviewing lab results for a pregnant patient. Which lab result will the nurse immediately report to the healthcare provider?

The nurse is caring for an 11-year-old child during a well visit. Which vaccine will the nurse prepare to administer?

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

A school nurse is talking with a 13-year-old non-binary student at their annual health screening visit. Which statement by the adolescent will the nurse prioritize?