During a prenatal intake interview, the nurse is in the process of obtaining an initial assessment of a 21-year-old Hispanic patient with limited English proficiency. It is important for the nurse to:

provide the patient with handouts.

speak quickly and efficiently to expedite the visit.

assess whether the patient understands the discussion.

use maternity jargon in order for the patient to become familiar with these terms.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect because providing the patient with handouts is not enough to ensure effective communication. The handouts may not be in the patient's preferred language or may use unfamiliar words or concepts. The nurse should also use other methods, such as interpreters, translators, or visual aids, to convey information to the patient.

Choice B reason: This is incorrect because speaking quickly and efficiently may hinder the patient's comprehension and increase the risk of misunderstanding. The nurse should speak slowly and clearly, using simple and common words, and allow time for the patient to ask questions or clarify information.

Choice C reason: This is correct because assessing whether the patient understands the discussion is essential for effective communication and patient education. The nurse should use techniques such as teach-back, ask-me-3, or show-me to verify the patient's understanding and address any gaps or misconceptions.

Choice D reason: This is incorrect because using maternity jargon may confuse the patient and create barriers to communication. The nurse should avoid using medical terms, abbreviations, or slang that the patient may not be familiar with. The nurse should explain any necessary terms in plain language and use examples or analogies to illustrate them.

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Correct Answer is C

Explanation

Choice A reason: Anxiety due to hospitalization is not a likely cause of the signs reported by the patient. Anxiety can cause some symptoms, such as headache, palpitations, or sweating, but it does not cause visual changes or epigastric pain. Anxiety is also not a common complication of pregnancy-induced hypertension, which is a condition characterized by high blood pressure and protein in the urine.

Choice B reason: Effects of magnesium sulfate are not a likely cause of the signs reported by the patient. Magnesium sulfate is a medication used to prevent seizures and lower blood pressure in patients with pregnancy-induced hypertension. It can cause some side effects, such as flushing, nausea, or drowsiness, but it does not cause headache, visual changes, or epigastric pain. In fact, magnesium sulfate can help relieve these symptoms by reducing the cerebral edema and vasospasm caused by pregnancy-induced hypertension.

Choice C reason: Worsening disease and impending convulsion are the most likely cause of the signs reported by the patient. These signs indicate that the patient is developing severe preeclampsia or eclampsia, which are life-threatening complications of pregnancy-induced hypertension. Preeclampsia is characterized by high blood pressure, protein in the urine, and signs of organ damage, such as headache, visual changes, epigastric pain, or decreased urine output. Eclampsia is the occurrence of seizures in a patient with preeclampsia. These conditions can lead to stroke, bleeding, placental abruption, or fetal distress, and require immediate medical attention.

Choice D reason: Gastrointestinal upset is not a likely cause of the signs reported by the patient. Gastrointestinal upset can cause some symptoms, such as nausea, vomiting, or abdominal pain, but it does not cause headache, visual changes, or epigastric pain. Gastrointestinal upset is also not a common complication of pregnancy-induced hypertension, which is a condition that affects the blood vessels and organs, not the digestive system.

A. Chadwick's sign. B. Hegar's sign. C. a positive pregnancy test. D. amenorrhea.

Correct Answer is D

Explanation

The correct answer is d. Amenorrhea.

Choice A: Chadwick’s sign is a non-specific, early sign of pregnancy that is typically characterized by a bluish discoloration of the cervix, vagina, and vulva. The Chadwick sign can typically be observed as early as six to eight weeks after conception, and commonly disappears shortly after birth. However, it’s not a definitive indication of pregnancy, and the absence of it on physical exam does not exclude a potential pregnancy.

Choice B: Hegar’s sign is a non-specific indication of pregnancy that is characterized by the compressibility and softening of the cervical isthmus (i.e., the portion of the cervix between the uterus and the vaginal portion of the cervix). It typically presents between the fourth and sixth week of pregnancy and may be present until the 12th week of pregnancy. However, the Hegar sign is not a definitive indication of pregnancy, and the absence of it does not exclude a potential pregnancy.

Choice C: A positive pregnancy test By 10 weeks, a home pregnancy test would almost certainly show a positive result if the woman is pregnant. This is because the hormone human chorionic gonadotropin (hCG), which is produced by the placenta after implantation of the embryo into the uterine wall, would be present in high enough levels to be detected by the test. However, a positive pregnancy test is not a presumptive sign of pregnancy, but rather a probable one.

Choice D: Amenorrhea, or the absence of menstrual periods, is often considered the most presumptive sign of pregnancy. This is because it’s one of the first noticeable signs of pregnancy for many women. By 10 weeks of gestation, the woman would likely have missed two menstrual periods if she usually has regular cycles. However, while amenorrhea is a common early sign of pregnancy, it can also be caused by various other conditions or factors such as stress, significant weight loss or gain, or certain medical conditions. Therefore, a missed period should be followed up with a pregnancy test to confirm pregnancy.

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During a prenatal intake interview, the nurse is in the process of obtaining an initial assessment of a 21-year-old Hispanic patient with limited English proficiency. It is important for the nurse to:

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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