Chapter 5

The nurse caring for a woman at 32 weeks' gestation finds elevated protein and nitrate levels in the urine. What will the nurse assess for next? 1) Symptoms of pre-eclampsia 2) Symptoms of a urinary tract infection 3) Symptoms of gestational diabetes 4) Inadequate nutrition

2 1 Although an elevated urine protein level can indicate pre-eclampsia, elevated nitrate levels will cause the nurse to consider another problem as more likely. 2 With elevated protein and nitrate levels, the patient should be assessed for symptoms of a urinary tract infection, including dysuria, frequency, urgency, and/or incontinence. 3 Gestational diabetes is indicated by elevated glucose levels, not protein and nitrate levels, in the urine. 4 Inadequate nutrition is indicated by ketones in the urine.

A medication error occurred, and the nurse is preparing to complete an incident report. Which information is extraneous and should be excluded from the report? 1) Name of the client involved in the incident 2) Location of a completed incident report in the medical record 3) Date and time of the incident 4) Medication involved in the incident

2 1 Incident reports generally include the names and identifying information of any patients and health-care personnel involved, as well as information on witnesses. 2 There should be no entry in the medical record that an incident report was completed. 3 The location, time, and date of the incident should be included in the report. 4 The name of the medication should be included in the incidence report.

The nurse is providing care to a child who has suffered abuse. Which nursing action is appropriate? 1) Asking the child what he did to cause his parents to beat him so badly 2) Telling the child that the individual who hurt him is a bad person 3) Following protocols for mandatory reporting 4) Asking the child what really happened

3 1 The nurse must reassure the child that he or she has done nothing wrong. 2 The nurse should avoid making negative comments about the abuser and must follow established protocols for mandatory reporting, documentation, and use of available support services. 3 The priority nursing consideration regarding the abused child is to ensure the immediate safety of the child. 4 The nurse working with the abused child needs to say that he or she believes the child's story.

The nurse is caring for a woman who is 16 weeks pregnant. One child was born at term, and a set of triplets were born at 26 weeks' gestation (one of whom died at 3 years of age). She experienced two spontaneous abortions prior to 8 weeks of pregnancy and had one therapeutic abortion many years ago as a young teen. Document the GTPAL for this patient by filling in the appropriate number for each letter. G___T___P___A___L___

G6, T1, P3, A3, L3

Which term should the nurse use to describe a wrongful act that produced harm, regardless of whether or not the act was committed intentionally or unintentionally? 1) Tort 2) Crime 3) Negligence 4) Malpractice

1 1 A tort is the term the nurse uses to describe any wrongful act that produced harm, regardless of whether the action was intentional or unintentional. 2 The nurse would not use the term crime to describe this situation. 3 Negligence is the failure to provide care according to one's professional responsibility. 4 Malpractice is a term used to specify a type of tort in which the expected standards of care were not met.

The clinical instructor observes a student nurse collecting the client history of a new prenatal patient. Which question asked by the student indicates that he or she needs further education? 1) "Do you use drugs?" 2) "Have you ever been pregnant before?" 3) "Are your parents and siblings living?" 4) "What is your current living situation?"

1 1 Although it is important to learn about drug use, many patients do not consider alcohol or tobacco to be drugs and may not share this information. It is better to be specific and ask if the patient drinks alcohol or uses any tobacco products and then question her medication and drug use. 2 It is appropriate to ask if the woman has ever been pregnant before. 3 Asking if parents and siblings are still alive tells the nurse if there is a need to question further about cause(s) of death, depending upon how the patient answers. 4 Asking about the current living situation begins the process of learning if the father of the child is involved, who the woman lives with, and whether there are any safety issues related to where the woman lives.

A home health-care case manager often receives documents pertaining to the care of patients through a shared fax machine. The case manager is aware of how important it is to protect each patient's health information. Which action by the nurse ensures that the HIPAA requirements are met in this situation? 1) Having transmitting agencies call before any information is sent 2) Taking relevant information over the phone 3) Having the patient sign a consent form for information to be released 4) Not utilizing the fax machine; depending on the mail system

1 1 Case manager nurses need to maintain vigilance to protect the privacy of patient health-care information when sending and receiving messages. In this case, having the sending agency call prior to faxing information alerts the nurse to collect the information from the fax machine at the time it is received, securing the information so others do not have access to it. 2 Taking information over the phone must be done in a way that is protected and secured in order to ensure that HIPAA privacy aspects have not been breached. 3 Signing a consent form for information to be released is necessary to share information, but this ensures only the disclosure aspect of HIPAA—not the privacy aspect. 4 Sending information through the mail takes time and does not ensure the privacy of the information.

Who can provide informed consent for a school-aged pediatric patient? 1) Parent 2) Sibling 3) Physician 4) Grandparent

1 1 For children, it is the legal caregiver—namely, the parent or guardian—who signs the consent form. 2 A sibling who is 18 years or older, and is the patient's legal guardian, can provide informed consent; however, there is no indication that the sibling meets these requirements. 3 The physician is the person who obtains informed consent from the parent or legal guardian but cannot sign the informed consent form permitting a procedure. 4 A grandparent can provide informed consent if he or she is the child's legal guardian; however, there is no indication that the grandparent is the legal guardian in this scenario.

A woman comes for her first prenatal visit and learns the obstetrician will perform a complete physical examination. She asks the nurse, "Why is a complete physical required?" Which is the nurse's best response? 1) "Your general health will influence your pregnancy, so the doctor needs to do a complete examination." 2) "If you have health problems, the doctor needs to know so you can receive the treatment you need to return to health." 3) "This is a requirement for all newly pregnant women because the doctor wants to learn as much about you as possible." 4) "The doctor wants to make sure that the baby is healthy and that your pregnancy will progress without complications."

1 1 This explains the role of health in pregnancy and the need to examine the entire body without frightening the patient. 2 Telling the patient she may have health problems and may be in need of treatment may frighten her and implies there is a problem with the pregnancy. 3 Simply saying it is a requirement does not adequately explain the rationale for the procedure. 4 The doctor examines the woman, not the baby, so this statement is not accurate.

Using Naegele's rule, calculate the estimated date of delivery for a patient whose first day of the last menstrual period was October 8, 2016. 1) July 15, 2017 2) January 1, 2017 3) July 1, 2016 4) June 14, 2017

1 1 To calculate the due date, subtract 3 months (October - 3 months = July) and add 7 days (8 + 7 = 15), resulting in an estimated delivery date of July 15, 2017. 2 To calculate the due date, subtract 3 months (October - 3 months = July) and add 7 days (8 + 7 = 15), resulting in an estimated delivery date of July 15, 2017. 3 To calculate the due date, subtract 3 months (October - 3 months = July) and add 7 days (8 + 7 = 15), resulting in an estimated delivery date of July 15, 2017. 4 To calculate the due date, subtract 3 months (October - 3 months = July) and add 7 days (8 + 7 = 15), resulting in an estimated delivery date of July 15, 2017.

The nurse is unable to locate fetal heart tones in a woman who is at 10 weeks' gestation. What is the nurse's priority action? 1) Reassuring the woman that this is a normal finding 2) Notifying the provider immediately 3) Recommending complete bedrest 4) Scheduling the patient for an abdominal ultrasound

1 1 When fetal heart tones are not heard, the mother is likely to become concerned; she needs to be reassured that it is not uncommon for heart tones to be inaudible until 12 weeks of pregnancy. 2 Fetal heart tones may not be heard until 12 weeks of pregnancy, so there is no need to notify the provider immediately; however, the finding should be documented. 3 Fetal heart tones may not be heard until 12 weeks of pregnancy, so there is no need for bedrest. 4 Fetal heart tones may not be heard until 12 weeks of pregnancy, so there is no need for an ultrasound at this time.

A novice nurse attends a lecture regarding risk management. Which action should the nurse implement to reduce risks in practice? 1) Not discussing errors made 2) Purchasing liability insurance 3) Storing unused equipment in the halls of the unit 4) Questioning every order that the physician writes

2 1 Risk management also entails analyzing errors to determine causes and changing policy to reduce more errors. Nurses should report all errors in an effort to assist in the campaign to reduce medical errors. 2 A large part of risk management entails reducing costs related to lawsuits. The nurse is best protected by purchasing personal liability insurance. 3 Storing unused equipment in the hall eliminates the risk of contamination but could increase risks due to injury. 4 The nurse does not need to question every order that a physician writes; the nurse is responsible for questioning only orders that may injure patients.

The nurse is examining a woman who is at 20 weeks' gestation. Which findings does the nurse consider appropriate at this stage of pregnancy? (Select all that apply.) 1) Fundal height - 20 cm 2) Fetal heart rate - 148 bpm 3) Quickening 4) +1 glycosuria 5) 3-lb weight loss

1,2,3 1. At 20 weeks, the fundal height should be 20 cm, so this is an expected finding. 2. Fetal heart rate between 110 and 160 bpm is an expected finding. 3. Quickening, or fetal movement, should be felt between 16 and 22 weeks, so this is an expected finding. 4. Glucose in the urine is never an expected finding and could indicate gestational diabetes. 5. By 20 weeks' gestation, the woman should be steadily gaining weight, so weight loss is not an anticipated finding.

A nurse working on a medical-surgical unit wants to ensure that care is provided within the standard of nursing care. Which actions by the nurse are appropriate? (Select all that apply.) 1) Analyzing the position description 2) Reviewing and becoming familiar with the policy and procedure manual 3) Questioning the value of collaborating with other disciplines 4) Ensuring that the nursing process steps are practiced 5) Adhering to national standards of practice and care

1,2,4,5 1. This is correct. The nurse's specific job description contributes to defining the standard of care. Employers can limit but not expand the scope of practice, and the nurse is held to functioning within the scope of employment. 2. This is correct. Agency policies and procedures serve in defining the standard of care. 3. This is incorrect. In addition to the steps of the nursing process, nurses are expected to demonstrate competence within multiple areas of their professional role, including collaboration with the entire care team. 4. This is correct. A competent nurse adheres to the steps of the nursing process. 5. This is correct. A primary source for defining the standard of care is the prevailing national nursing standards. Nurses who follow national standards of practice and standards of care provide their patients with the best care possible and are far less likely to commit any unintentional act that may rise to the level of malpractice.

The nurse reviews a pregnant patient's medical record and sees G5, T2, P5, A1, L5. Which statements reflect an accurate analysis of this information? (Select all that apply.) 1) The woman has been pregnant a total of five times, including the current pregnancy. 2) The woman requested to have one pregnancy terminated. 3) Two of the children born alive died after birth. 4) One pregnancy resulted in the birth of quintuplets. 5) The woman adopted one of her children.

1,3 1. G5 indicates the woman has been pregnant a total of five times, and that includes her current pregnancy. 2. From this information, there is no way of knowing whether the abortion was spontaneous or therapeutic. 3. Because she had two term children and five preterm children but has only five living children, it is correct to interpret this information as indicating two children died after being born alive. 4. Because four past pregnancies resulted in seven children, it is apparent that at least one pregnancy resulted in a multiple birth; however, there is no way of knowing if one pregnancy was a multiple birth or if there were several multiple births, so the nurse cannot draw the conclusion that she had quintuplets. 5. Adopted children are not included in the GTPAL.

The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? (Select all that apply.) 1) Patient fell getting out of bed because the call light was not used. 2) Patient's name band was checked prior to providing all medications. 3) Patient's morning medications were administered in the early afternoon. 4) Patient states misunderstanding activity restrictions, and a wound is eviscerated. 5) Patient documentation did not include the appearance of an infiltrated IV site.

1,3,4,5 1. This is correct. One strategy to prevent instances of professional negligence is to ensure patient safety. The patient fell when getting out of bed because the call light was not used. Because there is no way of knowing if the patient knew how to use the call light, the nurse should be concerned with this situation. 2. This is incorrect. Checking the patient's name band before providing medications is not an action that is negligent. 3. This is correct. Providing medications beyond the prescribed time can be viewed as negligent care. 4. This is correct. Clear communication of directions and explanations and providing effective patient education regarding the patient's health-care requirements can help decrease the risk of bad outcomes; thus, the wound evisceration could be viewed as negligent care. 5. This is correct. Poor documentation about care, wounds, and IV sites could be viewed as negligent care.

A child on a medical-surgical unit experienced a code blue situation unexpectedly. The emergency situation has ended, and the child survived. The nurses are breaking for lunch and plan to process their feelings about the emergency. Which action by the nurses will facilitate this? 1) Discussing the event outside the hospital 2) Asking management for the use of a private room to debrief 3) Talking while riding in the staff elevator 4) Debriefing the situation at home

2 1 Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This also precludes nurses from discussing patient care in the home. 2 To comply with HIPAA, nurses cannot discuss events involving patients in any setting where the conversation can be heard by others, so a private room is the best solution for debriefing. 3 The nurses must also guard against other health professionals not directly involved with the patient overhearing their discussion; consequently, a staff elevator is not acceptable. 4 Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This also precludes nurses from discussing patient care in the home.

The nurse is asked to participate on a committee to ensure that no breaches of confidentiality occur when providing care. Which actions help ensure patient confidentiality when providing care? (Select all that apply.) 1) Withholding private information from other staff unless needed for care 2) Sharing the name and diagnosis of clients upon request 3) Discussing patient care with nurses on other units 4) Restricting the discussion of patient care to the report room 5) Reviewing the patient's care needs with a designated health insurance agent

1,4,5 1. This is correct. The nurse has the responsibility to keep patient information private and confidential. Actions that ensure patient confidentiality include sharing information only with staff who are directly involved in care and restricting discussion regarding patient care to the report room or other secure areas. 2. This is incorrect. Patient names and diagnoses should be shared only with those who are directly providing care. 3. This is incorrect. The nurse is able to review the patient's care needs with the designated health insurance agent. 4. This is correct. The nurse has the responsibility to keep patient information private and confidential. Actions that ensure patient confidentiality include sharing information only with staff who are directly involved in care and restricting discussion regarding patient care to the report room or other secure areas. 5. This is correct. The nurse has the responsibility to keep patient information private and confidential. Actions that ensure patient confidentiality include sharing information only with staff who are directly involved in care and restricting discussion regarding patient care to the report room or other secure areas.

The nurse reviews a woman's quadruple screen. Which finding indicates a higher risk for Down syndrome in the fetus? 1) Elevated alpha-fetoprotein level 2) Elevated hCG level 3) Elevated unconjugated estriol level 4) Low level of inhibin A

2 1 An elevated alpha-fetoprotein level indicates a potential neural tube defect, not Down syndrome. 2 An elevated hCG level is an indication of potential Down syndrome. 3 A low unconjugated estriol level, not a high level, indicates a risk for Down syndrome. 4 An elevated level of inhibin A, not a low level, indicates a risk for Down syndrome.

The nurse cares for a newly diagnosed pregnant woman with a history of three spontaneous abortions in the first trimester and an emergency Cesarean section because of breech presentation with her last pregnancy. Which health-care provider is most appropriate to care for this patient? 1) Family physician 2) Obstetrician-gynecologist 3) Certified nurse midwife 4) Doula

2 1 The family physician is qualified to manage uncomplicated pregnancies, but this woman's pregnancy history indicates a risk for complications; thus, she needs more specialized care. 2 The obstetrician-gynecologist specializes in the care of pregnant women from preconception planning to postpartum recovery and is most appropriate to care for a patient with a history of complications. 3 The nurse midwife cares for women at low risk, and this woman's history of complications indicates the need for more specialized care. 4 A doula supports the woman and family during childbirth but does not have the education or ability to deliver a baby independently; she is inappropriate to care for a mother with a history of complications.

An adolescent patient with a sexually transmitted infection (STI) says to the nurse, "Promise you won't tell my parents about my condition." Which action by the nurse is appropriate? 1) Disclosing information to the parents 2) Communicating only necessary information 3) Respecting the patient's privacy and confidentiality 4) Honoring the patient's wishes

2 1 The nurse is not obligated to disclose this information to the parents. 2 Nurses are entrusted with sensitive information that at times must be revealed to other health-care personnel in order to provide appropriate care. In this case, the nurse may be required to report information to the state health department. 3 Although it is important to respect the patient's privacy and confidentiality, the nurse may be required to report information to the state health department. 4 It may not be possible to honor the patient's wishes in this circumstance. In this case, the nurse may be required to report information to the state health department.

A pregnant woman looks over the required laboratory tests and asks the nurse why they need a rubella titer and varicella titer when she knows she has already received these immunizations as a child. Which is the nurse's best response? 1) "We have to be sure that you actually received these vaccines." 2) "Some people require booster shots to attain full immunity." 3) "Maybe the doctor didn't notice that you reported having had the vaccines." 4) "Even when people have received the vaccine, they still need to be tested for immunity."

2 1 This response damages the trust between the nurse and the patient because it is essentially saying the patient is not to be believed; thus, this is not the best answer. 2 This response explains why the titers are performed and is the best response. 3 This response is not accurate and puts the responsibility on the doctor instead of answering the patient's question. 4 Although this answer is correct, it is not complete and does not explain why the patient needs to be tested.

The nurse is collecting a patient's personal information to contribute to the client history. How should the nurse question the woman regarding physical abuse and safety in her living situation? 1) "Does your significant other ever hit you?" 2) "Are you happily married?" 3) "Tell me about your home life." 4) "Tell me about your husband."

3 1 A closed-ended question such as this, especially early in the nurse-patient relationship when trust has yet to be developed, is most likely going to be answered "no." 2 The patient may or may not be married, and this is a closed-ended question that will return only a "yes" or "no" answer. 3 This question is open-ended and makes no assumptions about the living situation; thus, it is most likely to return information that allows the nurse to question her further depending on what is said. 4 There are many different lifestyles, and not all pregnant women are married, so this question makes assumptions that may not be based in reality and could offend the patient.

A woman arrives at the clinic and tells the nurse she thinks she is pregnant. Which symptom, as related by the patient, does the nurse consider the best indicator of pregnancy? 1) Amenorrhea 2) Irritability 3) Positive urine human chorionic gonadotropin (hCG; home test) 4) Enlarged abdomen

3 1 Although amenorrhea is often the first sign a woman notices, it can be caused by other conditions; thus, it is not the best indicator of pregnancy. 2 Irritability is not an expected sign of pregnancy and can be caused by any number of factors, so it is not the best indicator of pregnancy. 3 A positive hCG result is the best indicator of pregnancy because this hormone is released only during a developing pregnancy. 4 An enlarged abdomen is not the best indicator of pregnancy, because it can be caused by a number of factors.

Which criterion should the nurse review to determine if an adolescent is considered legally emancipated? 1) Over the age of 18 years 2) Resides outside of the family home 3) Legally married 4) Receives money from parents each month

3 1 An adolescent who is over the age of 18 years is a legal adult, not legally emancipated. 2 An adolescent who lives outside the family home is not legally emancipated. 3 An adolescent who is legally married is considered legally emancipated. 4 An adolescent must be financially independent in order to be considered legally emancipated.

At which point will the nurse begin scheduling a pregnant woman for weekly obstetric visits? 1) 22 weeks 2) 28 weeks 3) 36 weeks 4) 38 weeks

3 1 At 22 weeks, the woman will be seen monthly unless problems occur. 2 At 28 weeks, the woman will begin appointments every 2 weeks. 3 At 36 weeks, the woman will begin weekly appointments. 4 At 38 weeks, the woman should have already started weekly appointments.

The nurse reviews a patient's medical record and sees the measurement of the ischial tuberosity is 8.5 cm. How does the nurse interpret this measurement? 1) The woman may be unable to carry the pregnancy to term. 2) The woman has an adequate blood supply to the fetus. 3) The woman may require a Cesarean section. 4) The woman will experience a prolonged labor.

3 1 Because the ischial tuberosity measurement is an indication of the smallest diameter of the pelvis through which the head must pass, it gives no indication of whether the pregnancy will be preterm or term. 2 Because the ischial tuberosity measurement is an indication of the smallest diameter of the pelvis through which the head must pass, it gives no indication of blood supply to the fetus. 3 Because the ischial tuberosity measurement is an indication of the smallest diameter of the pelvis through which the head must pass, a measurement less than 10 cm indicates she may not have a large enough opening to deliver vaginally. 4 Because the ischial tuberosity measurement is an indication of the smallest diameter of the pelvis through which the head must pass, it gives no indication of the length of labor.

While making rounds, the nurse enters a room and finds an infant patient's father violently shaking the infant. The father makes it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant's arms and legs. What priority action should the nurse take? 1) Discussing what she witnessed with the infant's mother 2) Discussing what she witnessed with the other nurses 3) Reporting what she witnessed and assessed to child protective services 4) Reporting what she witnessed and assessed to the local law enforcement agency

3 1 It is not appropriate at this time to discuss the findings with the infant's mother. The nurse does not know if the mother is aware of what is occurring, and it is best to have this further investigated. 2 It is not appropriate to discuss the findings with the other nurses; because of privacy regulations, this information should be shared on a need-to-know basis. 3 Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate child protective services agency. 4 This is not the priority nursing action.

The nurse receives a notice that the state board of nursing has become a member of the Nurse Licensure Compact. How does this change in the structure of the state board of nursing influence his ability to practice nursing? 1) The nurse can practice nursing only in the residing state. 2) The nurse can practice nursing in other states not listed in the compact. 3) The nurse is accountable to the state in which he and his patients reside. 4) The nurse has to obtain an additional license.

3 1 Multistate licensure privilege provides the authority to practice nursing in another state that has signed an interstate compact. 2 Multistate licensure privilege provides the authority to practice nursing in another state that has signed an interstate compact. 3 The mutual recognition model of nurse licensure allows a nurse to have a single license that confers the privilege to practice in other states that are part of the Nurse Licensure Compact. The nurse is held accountable for following the laws and rules of the state in which he or she practices or where the client is located. 4 There is no need to obtain an additional license.

The nursing instructor is evaluating the success of training provided to staff nurses on ways to reduce the incidence of pediatric medication errors. Which observation indicates the need for additional training? 1) Staff nurses are double-checking medication calculations. 2) Staff nurses are using liquid preparations. 3) Staff nurses are asking the pharmacy to prepare the exact doses. 4) Staff nurses are asking each other to validate placement of decimal points.

3 1 Nurses who double-check medication calculations, use liquid preparations, and ask another nurse to validate the placement of the decimal point are demonstrating that the training was effective. 2 Nurses who double-check medication calculations, use liquid preparations, and ask another nurse to validate the placement of the decimal point are demonstrating that the training was effective. 3 Nurses should not expect the pharmacy to prepare the medications in exact doses. 4 Nurses who double-check medication calculations, use liquid preparations, and ask another nurse to validate the placement of the decimal point are demonstrating that the training was effective.

The nurse is caring for a child on a medical-surgical unit that has just implemented electronic medical records for patient documentation. The child's parent asks the nurse about the facility's computerized system for keeping patient information, especially in regard to confidentiality. Which is the best response by the nurse? 1) "I can see why you're worried, with all the computer hackers out there these days." 2) "Our system was designed with a lot of input from nursing staff." 3) "Information in the electronic medical record requires a password to retrieve." 4) "Don't worry; your child's information is always safe."

3 1 Reminding the patient that there is indeed cause for privacy concerns is not as therapeutic as explaining that the system requires a password. 2 Nurses need to be involved with the design, implementation, and evaluation of electronic medical records to maximize their use and effectiveness, but this does not ensure security. 3 Maintaining privacy and securing data are significant issues. One way that computers can protect data is with the use of passwords; only those individuals who have legitimate access to the data are provided a password. 4 Information in a computer data system may not always be safe, and it is inappropriate for the nurse to say this.

Which entity may allow a peer assistance program for a nurse who is found guilty of providing patient care while impaired by drugs or alcohol? 1) The unit manager 2) The patient's family 3) The state board of nursing 4) The president of the hospital

3 1 The unit manager cannot make this determination. 2 The patient's family cannot make this determination. 3 The state board of nursing is the only entity that can decide if a nurse who is found guilty of providing patient care while under the influence of drugs or alcohol can participate in a peer assistance program. 4 The president of the hospital cannot make this determination.

Which laboratory test does the nurse recognize as not part of the routine order set required for pregnant women? 1) Complete blood cell count (CBC) 2) Blood type and Rh 3) Papanicolaou (PAP) screen 4) Serum calcium level

4 1 A CBC is routinely drawn on all pregnant women to determine overall health and to screen for potential anemia. 2 All pregnant women should have their blood type and Rh status identified. 3 A PAP smear, or Papanicolaou screen, is routinely performed on pregnant women. 4 A serum calcium test is not routine.

A patient is late for her prenatal visit, and when she arrives she blames symptoms, suggesting a urinary tract infection for her late arrival. Upon examination, the nurse finds mild spotting and notes bruising on the woman's abdomen. What does the nurse suspect? 1) Preterm labor 2) Placental abruption 3) Pre-eclampsia 4) Domestic abuse

4 1 Although a bladder infection can increase risk for preterm labor, there is no indication of this problem at this time. 2 Abruptio placentae does not present with these symptoms. 3 Pre-eclampsia symptoms include protein in the urine, elevated blood pressure, and edema, so that is not a consideration with the presenting symptoms. 4 Arriving late for an appointment, urinary tract infection, and unexplained bruising will lead the nurse to suspect potential domestic abuse and to question the woman regarding her safety.

Which is the priority when providing care for a pediatric patient who is the victim of child abuse? 1) Exploring options for self-development 2) Improving quality of life by increasing self-esteem 3) Exploring options for getting help for the parent 4) Ensuring the child is safe

4 1 Exploring options for self-development and improving the quality of life by increasing self-esteem are long-term interventions for abused adults, not children. 2 Exploring options for self-development and improving the quality of life by increasing self-esteem are long-term interventions for abused adults, not children. 3 Although exploring options for getting help for the parent is important, this is not the priority. 4 When providing care to a child who is the victim of abuse, ensuring his or her safety is the priority.

During an assessment of a child in the urgent care clinic, the nurse notes that the child has a swollen and split lip. When asked how the child's lip injury occurred, the parent responds, "We are here for my child's ear, not my child's lip." Which is the rationale for reporting this incident? 1) The child reports that a parent caused the injury. 2) The lip injury is unrelated to the ear infection. 3) The nurse can be sued if there is abuse. 4) The suspected abuse must be reported.

4 1 Most children will not accuse an abuser; rather, they generally protect the abuser. 2 The lip injury being unrelated to the ear infection is not a reason to report the injury. 3 The reason for the law is that experts can assess the situation and determine if abuse has occurred. The nurse is protected by good faith immunity. 4 Suspected child abuse must be reported by law. Health-care personnel are protected by good faith immunity because the ultimate goal is the protection of the child.

The nurse admits a patient who arrives late for her appointment. The examination demonstrates vaginal spotting, anxiety and depression, reports of alcohol abuse, and bruising on the chest and abdomen. Which question is most appropriate for the nurse to ask? 1) "Do you have reliable transportation?" 2) "Have you considered giving the baby up for adoption?" 3) "Are you experiencing any rhythmic abdominal pain?" 4) "Has your partner ever hit you during a fight?"

4 1 Reliable transportation is of no significance in this situation. 2 It is not the nurse's place to suggest adoption unless the woman raises the option and says she is considering it. 3 Although abdominal bruising could induce preterm labor if severe, that is not the priority question to pursue. 4 The woman is demonstrating multiple warning signs of domestic abuse, so the nurse should question the woman regarding her safety.

Which potential complication is the nurse unlikely to associate with amniocentesis? 1) Spontaneous abortion 2) Leaking of amniotic fluid 3) Infection 4) Maternal liver damage

4 1 Spontaneous abortion is a potential complication following amniocentesis. 2 Leaking of amniotic fluid is a potential complication following amniocentesis. 3 Infection is a potential complication following amniocentesis. 4 Maternal liver damage is highly unusual and is not normally associated with amniocentesis.

Which information should the nurse include when teaching a pregnant patient who is scheduled to have an abdominal ultrasound? 1) Pain medication will be administered before the procedure. 2) Do not eat or drink anything for 4 hours prior to the procedure. 3) The probe will be inserted through the vagina. 4) Do not empty your bladder prior to the procedure.

4 1 There is only mild pressure on the abdomen during the procedure, so there is no need for analgesia. 2 Women will be required to push fluids in order to enter the procedure with a full bladder. 3 A transvaginal ultrasound, not an abdominal ultrasound, requires insertion of the probe into the vagina. 4 It is important for the patient to have a full bladder during the procedure, so teaching her not to empty her bladder is important.

From which child should the nurse obtain assent during the informed consent process? 1) A 4-year-old patient 2) A 5-year-old patient 3) A 6-year-old patient 4) A 7-year-old patient

4 1 This child is not developmentally capable of providing assent. 2 This child is not developmentally capable of providing assent. 3 This child is not developmentally capable of providing assent. 4 When a child is 7 years of age or older, assent is commonly secured. In seeking assent, the health-care team and parents, caregiver, or guardian include the school-aged child or adolescent in the decision-making process. Feedback from the child is solicited as part of assent, or agreement, and the child is asked if she or he has any questions or concerns about the course of medical treatment.