A 25-year-old female, with no prenatal care, is brought into your LAD unit by ambulance with vagina bleeding Based upon what she thinks in her LMP, she is suspected of being 26 weeks of gestation. The patients combative, yelling at staff, and refuses to change into a patient gown. The nurse suspects possible drug use and history of psychological disorders. She has had no prenatal care. What is not an appropriate nursing action at this time?

Ensure that the patient's external environment is free from excessive stimuli.

Ask her what drugs she has taken and when was the last time.

Administer prescribed sedatives.

Perform a vaginal exam.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Ensuring a calm environment by minimizing excessive stimuli is important for the safety and well-being of the patient.

B. Asking about drug use is essential to understand potential risks and provide appropriate care.

C. Administering sedatives to a combative patient without assessing the situation further could be dangerous. It could harm the patient and fetus, especially if drug use or psychological disorders are suspected.

D. Performing a vaginal exam is necessary to assess bleeding and determine if there are any signs of preterm labor or other complications.

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Correct Answer is C

Explanation

A. May 1 is not correct; this would be too early by several months.

B. July 8 is not correct; this date is too far out for the due date based on the LMP provided.

C. To calculate the due date using Naegele's rule, you add 7 days to the first day of the last menstrual period (LMP) and then subtract 3 months. Given: LMP: April 15th Step 1: Add 7 days to the LMP: April15th + 7 days= April 22nd Step 2: Subtract 3 months: April22nd – 3 months = January 22nd

D. January 22 is close but not the correct date by the standard calculation of 280 days.

A. Assess for lethargy and poor tone. B. Provide early feeding, C. Assess transcutaneous bilirubin level at birth. D. Assess for fracture of the clavicle due to the high possibility of LGA.

Correct Answer is C

Explanation

A. Lethargy and poor muscle tone are common in infants of diabetic mothers due to the risk of hypoglycemia.

B. Early feeding is crucial to help regulate blood glucose levels and prevent hypoglycemia.

C. While newborns of diabetic mothers may be at risk for jaundice, assessing bilirubin levels at birth is not typically prioritized in the immediate care plan unless clinical signs of jaundice are present.

D. Fractures, especially clavicle fractures, are common in infants of large gestational age (LGA), so assessing for birth injuries is a priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working in the prenatal clinic has a patient who states her last menstrual period was April 15th. Using Nagelle's rule, what is her due date?

Correct Answer is C

Explanation

You are caring for an infant of a diabetic mother. Which of the following actions would not be included in your plan of care related to this diagnosis

Correct Answer is C

Explanation

The nurse teaches a couple that the diaphragm is an excellent method of contraception providing that the woman does which of the following?

You have just completed an inservice on the high risk neonate which responses of the nurses would indicate teaching was successful or teaching needs to be reinforced?

Place the following in order from first to last

A client tells the nurse she is to have a cerclage and wants to know why the doctor is going to do this. The nurse provides education about a cerclage. Which statement indicates teaching needs to be reinforced?

A patient is being taught about tests for gestational diabetes. Teaching was effective when the patient states the following

Your patient received an epidural approximately 30 minutes ago. You notice late decelerations while evaluating the FHR tracing, Which of the following might be reasons that late decelerations occurring? (Select all that apply).

What is the duration of the contractions in this strip. Answer with a range in seconds in lower case-example: "20 to 30" or "50 to 60" seconds space like in the example or you may get marked wrong

A patient has a BMI 16 and weighs 96lbs and asks what the appropriate amount of weight she should gain with har pregnancy. Which of the following would be the best answer