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| Section | Weight | Objectives |
|---|---|---|
| Psychosocial Integrity | 6–12% | |
| Physiological Integrity | 43–67% | - Basic Care and Comfort - Reduction of Risk Potential - Physiological Adaptation - Pharmacological and Parenteral Therapies |
| Safe and Effective Care Environment | 17–33% | - Management of Care - Safety and Infection Control |
| Health Promotion and Maintenance | 6–12% |
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297. Frage
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
Antwort: A
Begründung:
Explanation/Reference:
Explanation:
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
298. Frage
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
Antwort: B
Begründung:
Explanation/Reference:
Explanation:
(A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants.
Complications are hemorrhage and retinal detachment. (B, C, D) O2concentration is too high.
299. Frage
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It's not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best?
Antwort: B
Begründung:
Explanation/Reference:
Explanation:
(A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization.
(C) Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?
300. Frage
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
Antwort: C
Begründung:
(A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
301. Frage
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
Antwort: B
Begründung:
Explanation/Reference:
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
302. Frage
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