A patient who is 6 months pregnant has sought medical attention, saying she fell down the stairs. Which scenario would cause an emergency department nurse to suspect that the woman has been battered?

Correct Answer: C

Rationale: In this scenario, the emergency department nurse would be most likely to suspect that the woman has been battered based on the presence of injuries on various parts of her body that are in different stages of healing. This pattern of injuries, known as the "battered woman syndrome," is a red flag for domestic violence. The varying stages of healing indicate that the injuries are not from a single accidental fall down the stairs but rather from repeated incidents of physical abuse. Additionally, the fact that the injuries are in different locations on the body further suggests that they are not the result of a single traumatic event. This situation warrants further investigation and intervention to ensure the safety and well-being of the pregnant woman and her unborn child.

Correct Answer: D

Rationale: Syphilis is one of the STIs that can cause one of the TORCH infections in a fetus. TORCH infections are a group of infections that can be passed from a pregnant woman to her fetus and include toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, and syphilis. When a pregnant woman with untreated syphilis transmits the infection to her fetus, it can result in congenital syphilis, which can have serious consequences such as stillbirth, prematurity, low birth weight, and developmental delays. Syphilis is thus an important infectious cause of prenatal and neonatal morbidity and mortality.

Correct Answer: D

Rationale: The correct nursing intervention that is written correctly is option D. The intervention "Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM" is clear, specific, and provides a specific time frame for the activity. It is important in nursing documentation to be precise and clearly state the details of the intervention to ensure effective communication among healthcare team members. This intervention also specifies the frequency and duration of the ambulation activity, which helps in ensuring continuity of care and proper execution of the intervention for the patient.

Correct Answer: A

Rationale: Analysis is the step of the nursing process being used when the nurse decides whether an ethical dilemma exists. During the analysis step, the nurse gathers and interprets data to make sense of a clinical situation. In the case of ethical dilemmas, the nurse would assess the situation, gather relevant information, and analyze it to determine if there is a conflict in values, beliefs, or principles, which would classify it as an ethical dilemma. Once the nurse identifies the existence of an ethical dilemma through analysis, they can then move on to the planning phase to decide on a course of action.

Correct Answer: A

Rationale: A. Take the medication with a small meal at the same time: Bisphosphonate medications should be taken with a small meal rather than on an empty stomach to enhance absorption and reduce the risk of gastrointestinal side effects.