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 B

Explanation

Choice A reason: Holding their head upright and sitting unsupported are signs that an infant may be ready for solid foods. These motor skills indicate that the baby has enough control to handle swallowing food safely.

Choice B reason: Pushing food out with their tongue is known as the tongue-thrust reflex, and it is a sign that the infant may not be ready for solid foods yet. This reflex prevents choking and generally diminishes between 4 and 6 months of age.

Choice C reason: Grasping small objects and not letting go demonstrates that the baby has developed fine motor skills, which are also important for starting solid foods. However, this alone does not determine readiness.

Choice D reason: Being between 4 and 6 months old is an appropriate age range for introducing solid foods, as long as other readiness signs are also present. Age alone is not the sole indicator of readiness for solid foods.

A. The child will have intellectual delays. B. Cerebral palsy is a genetic disorder. C. The child will have a shortened lifespan. D. This is a non-progressive disorder.

Correct Answer is D

Explanation

Choice A reason: While some children with cerebral palsy may have intellectual delays, it is not accurate to generalize this condition as affecting all children with cerebral palsy. The extent of intellectual involvement can vary widely. Therefore, stating this as a definite teaching point may not be appropriate for every child.

Choice B reason: Cerebral palsy is not typically considered a genetic disorder. It is most commonly caused by damage to the developing brain either during pregnancy, childbirth, or shortly after birth. Factors that contribute to cerebral palsy can include infections, lack of oxygen, and traumatic injuries, but it is not primarily a genetic condition.

Choice C reason: While cerebral palsy can impact a child's overall health and development, stating that it will shorten the child's lifespan is not necessarily true. Many individuals with cerebral palsy live into adulthood, and lifespan can vary widely depending on the severity of the condition and the presence of associated health issues.

Choice D reason: Cerebral palsy is accurately described as a non-progressive disorder. This means that while the symptoms of cerebral palsy can change over time (due to growth, development, and other factors), the underlying brain injury does not worsen. Understanding that cerebral palsy is non-progressive can help parents focus on managing symptoms and improving their child's quality of life.

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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 assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

Correct Answer is B

Explanation

The nurse is teaching parents about their child newly diagnosed with cerebral palsy. What will the nurse include in the teaching?

Correct Answer is D

Explanation

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