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: Applying a cold pack to the affected area is the most appropriate intervention for managing hemarthrosis (bleeding into the joint) in a patient with haemophilia A. Cold therapy helps reduce pain, swelling, and inflammation by constricting blood vessels, which can slow down bleeding. This intervention also provides comfort to the patient and helps manage the acute symptoms of hemarthrosis effectively.

Choice B reason: Administering ibuprofen for pain is not recommended for patients with haemophilia A because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding by inhibiting platelet function. Instead, acetaminophen (Tylenol) is often preferred for pain management in these patients as it does not have the same blood-thinning effects.

Choice C reason: Performing range-of-motion exercises is not appropriate during the acute phase of hemarthrosis. Movement and exercise can exacerbate bleeding and increase pain. It is essential to allow the joint to rest and stabilize before considering gentle range-of-motion exercises during the recovery phase. Immediate management should focus on controlling bleeding and reducing inflammation.

Choice D reason: Placing the leg in a dependent position (lower than the heart) is not recommended for managing hemarthrosis. Elevating the affected limb is a better approach as it helps reduce swelling and pain by promoting venous return and minimizing blood flow to the affected area. The dependent position can increase blood flow to the joint, potentially worsening the bleeding and swelling.

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 caring for a patient with haemophilia A who is experiencing hemarthrosis of the knee. Which intervention will the nurse perform?

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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