2TIPS Read question carefully. Be sure you know what it is asking What to do “FIRST” or to select action that is “BEST”Look for key words (except, not, first, next)Attempt to answer question before you look at answers
3TIPS ABC’s Maslow’s hierarchy Safety ASSESS first, then intervene Calling the MD is not usually the first response by the nurseVisualize the position
4Fluid replacement Pain relief Emotional support Respiratory therapy A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is most important for the nurse to include on the patient’s plan of care?Fluid replacementPain reliefEmotional supportRespiratory therapyLook first at the stem of the question. The words “most important” mean that this is a priority question. There is probably more than one answer choice that is a correct nursing action, but it will not be the most important or highest priority action.LOOK AT THE ANSWER CHOICES:Use Maslow’s hierarchy to establish priorities. Recognize the answers that are both physical and psychosocial. Eliminate the psychosocial ones. Think about the ABCsThe answer is fluid replacement…
5b. Knowledge deficit: nutrition in pregnancy The nurse obtains a diet history from a pregnant 16 year old. The client tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milkshake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data?a. Altered nutrition: more than body requirements related to high fat intakeb. Knowledge deficit: nutrition in pregnancyc. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancyd. Risk for injury: fetal malnutrition related to poor maternal dietLOOK AT THE ANSWER CHOICES: eliminate psychosocial ones….B is psychosocial…which is more important that the diet contains too much fat or that is does not contain enough nutrients?
7b. A one day old is crying and the anterior fontanel is bulging. The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first?a. A two day old infant is lying quietly alert with a heart rate of 185.b. A one day old is crying and the anterior fontanel is bulging.c. A 12 hour old infant is being held; the respirations are 45 breaths/minute and irregular.d. A five hour old infant is sleeping and the hands and feet are blue bilaterally.This is about setting priorities….Reword the question…Which infant is most unstable?Remember the ABC’s.Physical instability of patient is the nurse’s first concern..Most unstable patient should be seen first.ANSWER IS A: infant has tachycardia, normal resting heart rate is Requires further investigation
8a. Discourage stimulation of the baby by rocking. A one day old newborn diagnosed with intrauterine growth retardation is observed by the nurse to be restless, irritable, fist-sucking, and having a high-pitched shrill cry. Based on this data, which of the following actions should the nurse take FIRST?a. Discourage stimulation of the baby by rocking.b. Tightly swaddle the infant in a flexed position.c. Schedule feeding times every three to four hours.d. Encourage eye contact with the infant during feedings.Reword the question: What do you do for an infant experiencing drug withdrawal?Incorrect: Rocking helps infant feel more comfortableCORRECT: promotes infant comfort and securityIncorrect: small frequent feedings are preferredIncorrect: may result in overstimulation of infant
9a. “You will probably need less insulin while you are breastfeeding.” The nurse is caring for a woman at 37 weeks gestation. The client was diagnosed with insulin-dependent diabetes mellitus at 7 years of age. The client states, “I am so thrilled that I will be breastfeeding my baby.” Which of the following responses by the nurse is BEST?a. “You will probably need less insulin while you are breastfeeding.”b. “You will need to initially increase your insulin after the baby is born.”c. “You will be able to take an oral hypoglycemic instead of insulin after the baby is born.”d. “You will probably require the same dose of insulin that you are now taking.”Reword the question…What are the insuline requirements for the breastfeeding diabetic?CORRECT: bf has antidiabetogenic effectINCORRECT: insuline needs will decrease due to antidiabetogenic effect of bf and physiological changes during early pp periodINCORRECT: Client has IDDM; requires insulinINCORRECT: During third trimester, insulin requirements are increased due to insulin resistance.
10SELECTING THE MOST THERAPEUTIC RESPONSE Eliminate “don’t worry”Offers false reassuranceEliminate “explore” answersDon’t be a junior psychiatristDon’t ask “why?”Implies disapproval of patientEliminate authoritarian answersNurse telling patient what to doEliminate “focus on the nurse” answers“That happened to me once.”
11a. “If you are that concerned, you should refuse the procedure.” The nurse at the birthing facility is caring for a primiparous woman in labor who is 4 cm dilated, 25% effaced, and whose fetal vertex is at +1. The physician informs the patient that an amniotomy is to be performed. The patient states, “My friend’s baby died when the umbilical cord came out when her water broke. I don’t want you to do that to me!” Which of the following responses by the nurse is BEST?a. “If you are that concerned, you should refuse the procedure.”b. “The procedure will help your labor go faster.”c. “That should not happen to you since the baby’s head is engaged.”d. “We will monitor you carefully to prevent cord prolapse.”Reword the question…what is the most therapeutic response? BEST indicates there may be more than one correct responseNeed to know what is an amniotomyGiving advice, nontherapeuticDoesn’t respond to patient’s concernsCORRECT: umbilical cord prolapse usually occurs when presenting part is not yet engagedMonitoring will not prevent cord prolapse
12d. “When I ovulate, my cervix will feel firm.” The nurse is teaching a class on natural family planning. Which of the following statements, if made by a client, indicates that teaching has been successful?a. “When I ovulate, my basal body temperature will be elevated for two days and then will decrease.”b. “My cervical mucus will be thick, cloudy, and sticky when I ovulate.”c. “Since I am regular, I will be fertile about 14 days after the beginning of my period.”d. “When I ovulate, my cervix will feel firm.”Reword: what is a true statement about natural family planning?BBT decreased prior to ovulation; after ovulation, temp increasesFertile mucus appears clear, thin, watery, stretchyCORRECT: ovulation occurs 14 days after start of menstrual period
13a. Teach the patient to rest in bed when the baby sleeps. The nurse in the postpartum unit cares for a patient who delivered her first child the previous day. During her assessment of the patient, the nurse notes multiple varicosities on the patient's lower extremities. Which of the following actions should the nurse perform?a. Teach the patient to rest in bed when the baby sleeps.b. Encourage early and frequent ambulation.c. Apply warm soaks for 20 minutes every four hours.d. Perform passive range of motion exercises three times daily.Reword: what is the best way to prevent thrombophlebitis?Focus in on key word: BEST.Remember high risk for developing DVT after birth..INCORRECT: bed rest can cause thrombophlebitisCORRECT: facilitates emptying of blood vessels in lower extremitiesNot a preventive measure; can be used to treat, must be ordered by MDEarly ambulation is more effective
14A woman comes to the clinic because she thinks she is pregnant A woman comes to the clinic because she thinks she is pregnant. Tests are performed and the pregnancy is confirmed. The patient’s last menstrual period began on September 8 and lasted for 6 days. The nurse calculates that her expected date of birth is:a. May 15b. June 15c. June 21d. July 8REWORD: How to calculate EDB OR EDC. Subtract three months, add seven days.CORRECT: B
15A woman comes to the clinic at 32 weeks gestation A woman comes to the clinic at 32 weeks gestation. A diagnosis of pregnancy induced hypertension is made. The nurse performs teaching. Which of the following statements, if made by the patient, indicates to the nurse that further teaching is required?a. “Lying in bed on my left side is likely to increase my urinary output.”b. “If the bed rest works, I may lose a pound or two in the next few days.”c. “I should be sure to maintain a diet that has a good amount of protein.”d. “I will have to keep my room darkened and not watch too much television.”REWORD: What is NOT ACCURATE about the care of a woman with PIH?This is a negative question…it can be reworded to say “All of the following are true except.”True: bed rest promotes good perfusion to the uterus; decreases BP and promotes diuresisTrue: causes diuresis; results in reduction of retained fluids; instruct to monitor wt daily and notify MD if notices abrupt increase even after resting in bed for 12 hoursTrue: replaces protein lost in urine; increases plasma colloid osmotic pressure; avoid salty foods; avoid alcohol; drink 8 glasses of water daily; eat foods high in roughageCORRECT: incorrect info; not necessary; diversional activity is helpful
16a. Below the umbilicus, on the mother’s left side. A woman comes to the physician’s office for a routine prenatal checkup at 34 weeks’ gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart rate?a. Below the umbilicus, on the mother’s left side.b. Below the umbilicus, on the mother’s right side.c. Above the umbilicus, on the mother’s left side.d. Above the umbilicus, on the mother’s right side.REWORD: The fetus is ROA: where would you best hear the FHT?Picture the fetus in utero; vertex means head down. Hear FHT best through back of fetus.B is correct.
17Where would you place the doppler to hear the FHT TONES? Mark with an X.
18b. Turn the patient on her left side During labor, the fetal heart rate drops below baseline into the 80’s during a contraction and does not return to baseline until after the contraction is over. The first action by the nurse should be to:a. Call the physicianb. Turn the patient on her left sidec. Start oxygen at 10 liters/minuted. Increase the patient’s IV rateREWORD the question: What is the nursing action for a late deceleration? SHOW NEXT SLIDEHold the phone…think before calling the MD. The test makers want to know what you would do, not what the doctor would do! All may be correct…think perfusion to uterus…B is correct
20a. Allow the client to ambulate with assistance A client who is 34 wks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are WNL and the client isn’t in labor. What nursing intervention should the RN perform?a. Allow the client to ambulate with assistanceb. Perform a vaginal exam to check for cervical dilationc. Monitor the amount of vaginal blood lossd. Notify the MD for a fetal HR of 130 bpmAnswer 3
22d. Aspirate the neonate’s nose and mouth with a bulb syringe A neonate begins to gag and turns a dusky color. What should the RN do first?a. Calm the neonateb. Notify the MDc. Provide 02 via face maskd. Aspirate the neonate’s nose and mouth with a bulb syringeREWORD: What do you do if an infant is choking?Remember ABC’s…
23The purpose of preconception care is to: a. Ensure pregnancy complications do not occurb. Identify women who should not get pregnantc. Encourage healthy lifestyles to facilitate families desiring pregnancyd. Ensure women know about prenatal careAnswer 3
24a. If I have changes in my vision, I will notify my MD. A patient with preclampsia has received education from the RN about her condition. What statement would indicate the need for more education?a. If I have changes in my vision, I will notify my MD.b. I will weight myself every morning and notify my MD if I notice a weight gain of 1 lb or greater in a week.c. I will count my babies movements twice per day, once in the morning and once in the evening after I eat.d. If I have a headache, I will take Tylenol.REWORD: All of the following about PIH are true EXCEPT:Answer 4
25a. Knee to chest position b. Cover the cord in a saline soaked gauze A patient’s amniotic membranes rupture. Prolapsed cord is suspected. What nursing intervention should be performed?a. Knee to chest positionb. Cover the cord in a saline soaked gauzec. Prepare the woman for a cesarean birthd. Start O2 by face maskAnswer 1
26a. Blood pressure, age, height/weight ratio. . Sandra Thomas comes to the clinic seeking confirmation of her pregnancy. The following information is obtained. She is 24 years old, is 5 feet 8 inches tall and weighs 107 lbs. She admits to having used cocaine several times during the past year and drinks alcohol occasionally. Her blood pressure is 108/70, pulse is 72, and her respirations at 16. Family history is positive for diabetes mellitus and cancer; her sister recently gave birth to a baby with a neural tube defect. Which characteristics place Ms. Thomas in a high-risk category?a. Blood pressure, age, height/weight ratio.b. Drug/alcohol use, age, family history.c. Family history, blood pressure, height/weight ratio.d. Family history, height/weight ratio, drug/alcohol use.Answer D
27b. Congenital anomalies of the central nervous system c. Preterm birth Screening at 24 weeks revealed that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:a. Macrosomiab. Congenital anomalies of the central nervous systemc. Preterm birthd. Low birth weightAnswer 1
28Chorionic villus sampling Amniocentesis Triple Screen A 40 yr. old gravida 4 at 10 weeks gestation asks which tests are available during the first or early second trimester to diagnose fetal anomalies. Which are appropriate?CHECK ALL THAT APPLYElectrocardiogramChorionic villus samplingAmniocentesisTriple ScreenExternal fetal monitoringAnswer: 2, 3, 4
29Which of the following are signs of true labor? CHOOSE ALL THAT APPLY Contractions coming every minutesWalking around decreases strength of contractionsContractions are felt in the top of the fundusContractions increase in strength and frequencyPassage of mucous and blood from vaginaAnswer d, e
30CalculationHow many ounces of formula does a 6.6 lb newborn need every 24 hours, based on caloric requirements? (formula=20cal/oz)12 ounces16 ounces20 ounces24 ouncesMust know that 2.2 lb = 1 kg and 110kcal/kg/24 hr.3 kg x 110 kcal=330 kcal divided by 20 cal/oz=16.5 ounces
31Blood tinged mucous on perineal pad Baseline FHR 140 Upon admission to L&D, the woman states,”My water broke last night, but my labor pains started two hours ago.” Which of the following assessment data are cause for concern? CHECK ALL THAT APPLYMaternal VS: T.99.5F HR80 R24 BP 130/80Blood tinged mucous on perineal padBaseline FHR 140Peripad stained with green fluidThe client states” This baby keeps kicking me.”A and D are correct
32On examining Sharon two hours after her delivery, you find that she has completely saturated a perineal pad with 15 minutes. Your first nursing action is to:a. Palpate the fundusb. Administer an oxytocic drugc. Check her vital signsd. Increase her intravenous fluid rate
33a. You have to wait until the vaginal bleeding stops A client in the 4th stage of labor asks to use the bathroom for the first time following delivery. The client has oxytocin (Pitocin) infusing which response by the RN is best?a. You have to wait until the vaginal bleeding stopsb. You have to wait until the oxytocin stops infusingc. You may use the bathroom with my assistanced. You may get up to the bathroom anytime you likeThis is asking you to select the BEST answer. It could mean that all are correct, but one is the best.You must think about what is the fourth stage of labor…..How is the patient feeling after birth? Possible postural hypotension, dizziness?What is oxytocin…action, side effects…Consider patient SAFETY!Correct answer is #3.