- (Topic 2)
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
Correct Answer:C
(A) This answer is an incorrect application of the GTPAL method.
One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20–33 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2).
- (Topic 4)
A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:
Correct Answer:B
(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.
- (Topic 2)
In addition to changing the mother??s position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
Correct Answer:D
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was ??wet?? with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
- (Topic 5)
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
Correct Answer:D
(A) Asking the client to provide an explanation for her feelings is often intimidating. (B) This response is probing and may make the client feel used and valued only for the information she can provide. (C) This underrates the client??s feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. (D) The emphasis is on working with the client. It shows that there is hope for change through collaboration.
- (Topic 1)
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
Correct Answer:B
(A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This statement is true. (C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. (D) Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.