The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?
“Did you know that your baby’s development is affected by the type of drugs you use during the pregnancy?”.
“Are you aware that using nonprescription medication during pregnancy may be regarded as child abuse?”.
“What drugs have you used during your pregnancy?”.
“Have you ever used street drugs?”.
The Correct Answer is C
The correct answer is choice C. “What drugs have you used during your pregnancy?”.
This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.
The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.
Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.
Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.
Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.
It also labels the patient as a drug user, which may offend her or make her feel ashamed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus.Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.
Choice A is wrong because documenting the findings is not a priority action in this situation.
The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.
Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.
It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.
Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.
Correct Answer is A
Explanation
The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.
The nurse should assess the infants’ respiratory status and intervene as needed.
Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.
Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.
The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.
Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.
The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood sugar: 40 to 80 mg/dL
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