网站首页  |  关于我们  |  最新公告  |  新闻动态  |  备考指南  |  下载中心  |  考点简介  |  培训基地展示  |  在线留言  |  联系我们
ISPN学习中心
    最新公告
    新闻动态
    下载中心
    法律声明
    备考指南
    考点简介
    培训基地展示
 
    
 
  

  

 
 
 首页信息中心 备考指南知识题库
 
ISPN考试模拟试题(442)

Question:

The nurse is planning care for four mothers and their newborns. After reviewing the clients’ charts, the nurse should make rounds on which of thefollowing clients first

1. An 18-year-old G2 P2 with an uncomplicated spontaneous vaginal delivery 12 hours ago who has abdominal cramps. 

2. A 35-year-old G4 P4 with an uncomplicated vaginal delivery 4 hours ago. The nurse’s notes indicated she soaked two peripads over the last 2 hours; fundus is firm. 

3. A 16-year-old G1 P1 with a caesarean section 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h. Reflexes are 2+, and the nurse’s notes indicate she has a headache. Vital signs are T 99.4˚F, P 88, R 20, BP 128/86. 

4. An 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain. Vital signs are T 99.8˚F, P 96, R 22.


 

 

The criteria for hemorrhage is saturating one pad per hour. The 35- year-old who delivered 4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration which would be the source of the bleeding. She needs to be evaluated first, based on the bleeding. 

The 18-year-old who has abdominal cramps is within normal limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will need pain medication. 

The 16-year-old status post cesarean section on magnesium sulfate is stable with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a postpartum client. The headache is the one area of concern for this client. 

The 18-year-old who is 2 days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk developing within her system. The vital signs for this client are slightly elevated, but this may be from the milk coming in and would require nursing evaluation but is not emergent. 

CN: Management of care; CL: Synthesize

Answer:2

翻译

 

问题:

护士正计划照顾四位母亲和她们的新生儿。看完病人的病历后,护士应该先查房下列哪位病人?

1.一名18岁的G2-P2患者,12小时前无并发症自然阴道分娩,腹部绞痛。

2.一名35岁的G4 P44小时前阴道分娩无并发症。护士的记录显示她在过去的两个小时里浸湿了两个衬垫,宫底牢固。

3.一名16岁的G1-P14小时前剖腹产,被诊断为先兆子痫,接受2/小时的硫酸镁治疗。反射为2+,护士的记录显示她头痛。生命体征为T 99.4˚FP 88R 20BP 128/86

4.一名18岁的G2 P2,两天前剖腹产,现在有严重的乳房疼痛。生命体征为T 99.8˚FP 96R 22

 

答案:2

出血的标准是每小时浸湿一个衬垫。这名35岁的产妇在4小时前分娩,每小时有一个衬垫浸湿。即使她的宫底牢固,但她可能经历了宫颈撕裂伤,这可能是出血的原因。首先要根据出血情况对她进行评估。

18岁的产妇腹痛在G2 P2的正常范围内,并且正经历产后疼痛,这种疼痛通常见于经产妇;她将需要止痛药治疗。

宫产术后使用硫酸镁的16岁产妇状况稳定,尿量充足,反射正常。她的生命体征在产后病人的正常范围内。头痛是这个病人担心的一个方面。18岁的产妇产后2天出现乳房疼痛,可能正在经历乳汁进入,但这并不表明她是母乳喂养还是奶瓶喂养;在这两种情况下,母亲的体内都可能有乳汁。这位病人的生命体征稍高,但这可能是乳汁进入引起的,需要护理评估,但不是紧急情况。

CN:护理管理;CL:综合

小编寄语:The secret of success is not merely to seek, but to wait.成功的诀窍不仅仅在于追求,更在于等待。

时间:2021/1/18 11:56:41
 
上一篇:ISPN考试模拟试题(441)                          下一篇:ISPN考试模拟试题(443)  
 
  
邮箱:cgfnscn2012@126.com   法律声明 Copyright 2012   版权所有  All Rights Reserved