27.2 Measuring Clinical Judgment within Nursing Practice

Recognizing Cues

Toni is a 16-year-old high school junior who has come to the family planning clinic to discuss options for birth control. Toni states she and her partner have discussed having sex. Toni does not want to get pregnant.

Toni lives in an apartment with two younger siblings, her mother, and grandfather. Toni does not work and often takes care of her siblings while her mother and grandfather are at work.

RCQ1.1 List the cues that are relevant to the purpose of Toni’s visit to the family planning clinic.

[Answers: 16 years of age, wants to discuss birth control, does not want to get pregnant]

Analyzing Cues

The nurse proceeds to obtain Toni’s health history and learns that she:

• is allergic to penicillin.
• has a medical history positive for asthma and takes albuterol and budesonide. (AIRSUPRA).
• is not currently taking any over-the-counter medications or herbal preparations.
• has a negative history of STIs.
• denies history of intimate contact except kissing and touching above the waist.
• denies any surgeries.
• has a family history of type 2 diabetes mellitus and HTN.

Clinical Data:
Height: 5 ft 3 in.
Weight: 135 lb
BP: 112/72

ACQ1.1. What is the relevant information obtained by the nurse during the health history?

Select all that apply.

1. history of asthma
2. taking budesonide for asthma
3. allergy to penicillin
4. family history of diabetes mellitus
5. negative history of STIs
6. weight 135 lb

[Answers: a, b, c, e, f]

Prioritizing Hypotheses

Before the nurse begins to discuss birth control options, Toni informs the nurse that the only methods of birth control she has heard about are condoms, the shot, and the pill.

PHQ1.1. The nurse identifies the priority problem at this time as                       .

1. knowledge deficit regarding birth control options
2. risk for unintended pregnancy
3. knowledge deficit regarding the transmission of STIs

[Answer: a]

Generating Solutions

The nurse continues to discuss birth control options with Toni.

GSQ1.1. What topics should the nurse include in the discussion about each method of birth control? Select all that apply.

1. effectiveness
2. adverse effects
3. benefits
4. how the option works
5. how often to take a home pregnancy test
6. consequences of unprotected sex

[Answers: a, b, c, d, f]

Taking Action

Nursing Notes: Toni expresses the need to learn more about different methods of birth control before making a decision. The nurse discusses over-the-counter (OTC), combined hormonal, and progestin-only birth control options with Toni. The nurse also provides pamphlets with illustrations of the methods.

Toni chooses combined oral contraceptives.

The following questions discuss the actions taken by the nurse. Identify if the actions taken by the nurse to assist Toni in safely and effectively using combined oral contraceptives as a method of birth control were correct or incorrect.

TAQ1.1. Discuss the signs and symptoms of adverse effects with Toni.

1. action correct
2. action incorrect

[Answer: a]

TAQ1.2. Provide Toni with a list of actions to take if she forgets to take a pill.

1. action correct
2. action incorrect

[Answer: a]

TAQ1.3. Discuss with Toni the use of the vaginal ring as a backup method.

1. action correct
2. action incorrect

[Answer: b]

TAQ1.4. Discuss with Toni a plan for setting a daily alarm to remember to take the pill.

1. action correct
2. action incorrect

[Answer: a]

Evaluating Outcomes

Nursing Notes: Three months later, the nurse makes a follow-up phone call to Toni. The nurse asks Toni several questions about her experience using oral contraceptives.

EOQ1.1. Which statement made by Toni best demonstrates to the nurse that the patient's education about using combined oral contraceptives was effective?

1. “I am lucky I am not pregnant.”
2. “The alarm I set on my cell phone has helped me remember to take the pill daily.”
3. “I went to my primary care doctor to find out why I had bleeding between my last two periods.”
4. “If I continue to take the pill for more than 2 years, I may not be able to get pregnant for at least 3 months.”

[Answer: b]

Recognizing Cues

Two years later, Toni stops taking the combined oral contraceptives because she broke up with her partner. Toni begins a relationship with a new partner, and 3 months into the relationship, she misses her period. Toni buys a home pregnancy test, and it is positive. Toni informs her partner and her mother about the positive pregnancy test.

Toni still lives at home with her siblings, mother, and grandfather. Both Toni and her partner work at a local convenience store.

Toni makes an appointment with an obstetric care provider’s office to begin prenatal care.

Health History: When completing the health history forms, Toni provides the following information:

• LMP: 8 weeks ago
• This is her first pregnancy.
• Current medications: albuterol and budesonide (AIRSUPRA)
• Denies routine use of over-the-counter medications, herbal preparations, and recreational/illegal substance use. Denies tobacco use but has drunk alcohol on two different occasions since her LMP.

RCQ2.1. What additional information would the nurse review in Toni’s completed prenatal health history form? Select all that apply.

1. gynecologic history
2. genetic history
3. STI history
4. immunizations
5. breast- or bottle-feeding desire

[Answers: a, b, c, d]

Analyzing Cues

Nursing Notes: The nurse continues to review the information on Toni’s completed prenatal health history form.

Identify the information in Toni’s health history that is a risk factor for complications during pregnancy and the information that is not a risk factor during pregnancy.

ACQ2.1. History of asthma

1. risk factor
2. not a risk factor

[Answer: a]

ACQ2.2. Alcohol use since LMP

1. risk factor
2. not a risk factor

[Answer: a]

ACQ2.3. Family history of HTN

1. risk factor
2. not a risk factor

[Answer: a]

ACQ2.4. Patient is 18 years old.

1. risk factor
2. not a risk factor

[Answer: a]

ACQ2.5. Tobacco use

1. risk factor
2. not a risk factor

[Answer: b]

ACQ2.6. Current prescribed medications

1. risk factor
2. not a risk factor

[Answer: b]

Prioritizing Hypotheses

Nursing Notes: Toni is now 18 weeks pregnant and arrives at the office for a prenatal appointment.

The nurse is reviewing Toni’s prenatal lab work.

PHQ2.1. After reviewing the lab report, the nurse identifies the priority problem as                       .

[Answer: increased risk for neural tube defect]

Generating Solutions

GSQ2.1. Based on the priority problem, the nurse anticipates the health-care provider will order a(n)                       .

1. obstetric ultrasound
2. RhoGAM injection
3. ferrous sulfate
4. CVS testing

[Answer: a]

Taking Action

Toni is now 28 weeks pregnant and is seen at the office for a routine prenatal visit. During the visit, the nurse provides education on topics specific to Toni’s current gestation.

TAQ2.1. What does the nurse include in the prenatal education at this time? Select all that apply.

1. fetal movement counts
2. purpose of Rho(D) immune globulin (RhoGAM) injection
3. signs and symptoms of preterm labor
4. signs and symptoms of preeclampsia
5. genetic testing
6. CVS

[Answers: a, b, c, d]

Evaluating Outcomes

The nurse has completed providing prenatal education on the topics specific to Toni’s current gestation.

EOQ2.1. Which statement by Toni demonstrates the education provided by the nurse was effective?

1. “I need to count the baby’s movements 10 times a day.”
2. “I need to call the office or the on-call health-care provider if I notice any leaking of fluid from my vagina.”
3. “The baby’s movements should start slowing down during this last part of the pregnancy.”
4. “I do not need to worry about getting preeclampsia, since my BP has been normal.”

[Answer: b]

Recognizing Cues

Toni is now 30 weeks pregnant. Early this morning, Toni noticed some occasional lower back pains. The pains have now become stronger and are occurring every 8 to 10 minutes. Toni also noticed some pink-tinged mucus on the toilet paper after voiding.

Toni calls the office and discusses the backache and mucus with the prenatal nurse.

RCQ3.1. What additional information related to the back pains is most important for the nurse to obtain from Toni now? Select 4 that apply.

1. any leaking of fluid from the vagina
2. swelling in her feet
3. active fetal movements
4. abdominal cramping
5. pain with cramping
6. any difficulty in walking

[Answers: a c, d, e]

Analyzing Cues

Nursing Notes: The nurse instructs Toni to go to the labor and delivery (L&D) triage unit for an assessment.

After arriving at the L&D triage area, Toni is placed on the external fetal heart rate monitor and uterine contraction monitor, and the nurse performs an assessment on Toni.

ACQ3.1. Identify which assessment data obtained by the nurse are of most concern.

Select all that apply.

1. contractions every 6 minutes; palpate moderate quality
2. FHR 155 baseline, moderate variability
3. BP: 120/78; T: 97.8° F (36.5° C); P: 88; R: 16
4. pain level 4 out of 10
5. trace pedal edema
6. VE: cervix 2 cm/ 90 percent effaced/ vertex 0 station

[Answers: a, d, f]

Prioritizing Hypotheses

PHQ3.1. Based on the cues (data) that are of most concern, the nurse determines Toni                       

1. is experiencing preterm labor
2. has a placenta previa
3. has experienced spontaneous rupture of membranes

[Answer: a]

Generating Solutions

The nurse notifies Toni’s health-care provider (HCP) of the fetal monitor data and the patient’s symptoms. The nurse then receives a set of orders.

Identify the HCP orders that are expected and the orders that are not indicated for Toni’s diagnosis.

GSQ3.1. Continuous external fetal heart rate and uterine contraction monitoring

1. anticipated
2. not indicated

[Answer: a]

GSQ3.2. Magnesium sulfate 4 g bolus IV over 30 minutes, then 2 g per hour continuously

1. anticipated
2. not indicated

[Answer: a]

GSQ3.3. Betamethasone (Alphatrex) 12.5 mg IM every 12 hours for two doses

1. anticipated
2. not indicated

[Answer: a]

GSQ3.4. Oxytocin (Pitocin) IV per protocol

1. anticipated
2. not indicated

[Answer: b]

GSQ3.5. Prepare for cesarean section

1. anticipated
2. not indicated

[Answer: b]

GSQ3.6. Regular diet

1. anticipated
2. not indicated

[Answer: b]

Taking Action

Nursing Notes: The nurse implements the health-care provider’s orders. The following morning, Toni informs the nurse that she felt a gush of fluid coming from her vagina. She now feels lower abdominal pains coming and going every 5 minutes.

The FHR is 156. Uterine contractions are tracing every 5 minutes, lasting 45 seconds.

TAQ3.1. What is the nurse’s next action?

1. Check Toni’s temperature.
2. Palpate the uterus.
3. Notify the health-care provider.
4. Assess the color, amount, and consistency of the fluid.

[Answer: d]

Evaluate Outcomes

Nursing Notes: Preterm rupture of membranes is confirmed. The nurse also performs a vaginal exam, and Toni’s cervix is 4 cm/ 100 percent effaced/ vertex is +1 station. The nurse informs the HCP of the rupture of membranes, clear fluid, and change in vaginal exam. The nurse also informs the neonatal unit of Toni’s current status and expected preterm delivery.

EOQ3.1. Additional actions the nurse could anticipate and perform before notifying the HCP?

List two or three of the additional actions.

[Answers: Assess FHTs and uterine contraction pattern for strength and frequency.

Obtain Toni’s vital signs.

Obtain a neonatal consult to talk with parents due to delivering a preterm infant.]

Nursing Notes: Two hours after rupture of membranes, Toni receives an epidural for labor discomfort.

Six hours later, Toni spontaneously delivers a female infant, who cries with minimal stimulation.

The neonatal team is present and assigns an Apgar score of 5 at 1 minute and 9 at 5 minutes.

Ten minutes after the delivery of the baby, the placenta delivers spontaneously. The assessment of the placenta determines the placenta to be intact. The QBL is determined to be 350 mL. The health-care provider repairs a first-degree perineal laceration.

Toni’s partner and mother were supportive during Toni’s labor and birth.

Recognizing Cues

It is 3 hours after delivery, and Toni is in the mother/baby unit.

RCQ4.1. Toni notices a gush of fluid from her vagina and informs the nurse. The nurse assesses Toni. What data does the nurse obtain? Select all that apply.

1. consistency and location of the fundus
2. consistency, amount, and color of the lochia
3. vital signs
4. status of the baby
5. location of Toni’s support person
6. when Toni last voided

[Answers: a, b, c, f]

Analyzing Cues

ACQ4.1. Which cue (data) obtained during the nurse’s assessment of Toni is of most concern?

1. Fundus is at the umbilicus, deviated to the right, and firms with massage.
2. Lochia is heavy, dark red, with two 5-cm clots.
3. BP is 110/70; P is 96.
4. Toni has not voided since delivery.

[Answer: b]

Prioritizing Hypotheses

PHQ4.1. Based on the assessment cues (data) that are most concerning, the nurse concludes the priority need for Toni at this time is to                       .

1. empty her bladder
2. use the breast pump
3. take pain medication
4. be instructed to massage her uterus

[Answer: a]

Generating Solutions

GSQ4.1. Based on the identified priority need, what are the anticipated actions by the nurse in the correct sequence?

1. Assist Toni back into the bed.
2. Assist Toni to sit on the side of the bed.
3. Assess Toni’s fundus and lochia.
4. Ask Toni if she is experiencing any dizziness.
5. Instruct Toni in performing pericare.
6. Assist Toni to the bathroom.

1. 1, 3, 5, 6. 4, 2
2. 2, 4, 6, 5, 1, 3
3. 3, 2, 6, 5, 4, 1
4. 2, 6, 4, 1, 3, 5

[Answer: b]

Taking Action

The nurse is making rounds on Toni 2 hours later. Toni expresses the following concerns to the nurse:

• providing breast milk for the baby
• how often she and her partner can go to the NICU
• how much bleeding is considered normal
• the frequency and amount of urination

TAQ4.1. Identify the most important nursing education based on Toni’s current concerns.

1. Have Toni empty her bladder.
2. Show Toni how to use the breast pump.
3. Instruct Toni to call if bleeding is through more than one pad per hour.
4. Allow Toni’s partner to take Toni to the NICU.

[Answer: c]

Evaluate Outcomes

The nurse discusses the normal fluid shift that occurs in the immediate postpartum period. She reinforces the normal amount of blood loss (one pad per 1 to 2 hours) and shows Toni how to locate, assess, and massage the uterus. The nurse also instructs Toni to call the NICU about times to visit the baby.

EOQ4.1. Which statement by Toni demonstrates the education provided by the nurse was effective? Select all that apply.

1. “I should go to the bathroom every 2 to 3 hours for the next 2 days.”
2. “I will expect the uterus to need to be massaged every hour.”
3. “The NICU nurse let me know I can see the baby anytime.”
4. “I should use the restroom if my uterus is above my belly button.”
5. “Can you call the NICU to see if it’s okay for me to see the baby?”
6. “My uterus should be firm whenever I check it.”
7. “My bleeding should be red for the next few days.”
8. “I may pass small blood clots for the next day or so, but not larger than a golf ball.”

[Answers: a, c, d, f, g, h]

Recognizing Cues

Toni has successfully delivered. The baby, Drew, is immediately cared for by the baby nurse and the NICU team that had been called for the delivery of a 30-week-gestation neonate. The infant’s initial Apgar at 1 minute is 5, but after briskly drying the newborn and placing her on the warmed incubator bed, her 5-minute Apgar is 9. Drew’s weight is 1,450 g.

RCQ5.1. What additional monitoring would the nurse want to have placed for this newborn?

1. a temperature probe to monitor thermoregulation during the transitional period
2. telemetry to monitor cardiac and pulmonary function
3. a Foley catheter to monitor urine output and kidney function closely
4. an arterial umbilical catheter to monitor blood pressure and obtain frequent lab work.

[Answer: a]

Analyzing Cues

The premature newborn is taken to the NICU.

After arrival at the NICU, the NICU nurse keeps the newborn in the warmed incubator, connects her to cardiac and respiratory monitoring equipment, attaches a temperature probe, and performs an assessment.

ACQ5.1. Identify which assessment data obtained by the nurse is of most concern. Select all that apply.

1. heart rate of 156
2. pulse oximetry saturation of 72 percent
3. current temperature of 96.1° F (35.6° C)
4. respiratory rate of 20 with an irregular breathing pattern, including long pauses
5. acrocyanosis to hands and feet

[Answers: b, c, d]

Prioritizing Hypotheses

PHQ5.1. Based on the preceding assessment data, the nurse determines Drew                       .

1. is hypothermic and intermittently apneic
2. is tachycardic and cyanotic, requiring a cardiology consult
3. is currently in respiratory distress

[Answers: a]

Generating Solutions

The nurse prepares to notify the health-care provider of Drew's current temperature, irregular breathing pattern, and low oxygen saturation. Identify the interventions the nurse would anticipate or not anticipate being ordered by the health-care provider for Drew’s current condition.

GSQ5.1. Reapply the temperature monitoring device.

1. anticipated
2. not anticipated

[Answer: a]

GSQ5.2. Assess the infant’s blood glucose.

1. anticipated
2. not anticipated

[Answer: a]

GSQ5.3. Bottle-feed the infant with donor breast milk.

1. anticipated
2. not anticipated

[Answer: b]

GSQ5.4. Place oxygen via nasal CPAP to the infant’s nares.

1. anticipated
2. not anticipated

[Answer: a]

GSQ5.5. Decrease the incubator heating setting.

1. anticipated
2. not anticipated

[Answer: b]

Taking Action

The nurse has implemented the ordered interventions. Drew continues to have oxygen saturations in the high 70 percent or low 80 percent and exhibits much agitation and crying.

TAQ5.1. What is the nurse’s next action?

1. Check the placement of the CPAP nasal prongs.
2. Reapply the temperature monitoring device.
3. Call the health-care provider.
4. Prepare for newborn resuscitation.

[Answer: a]

Evaluate Outcomes

The nurse implements the next action. After 5 minutes, the nurse evaluates Drew to determine the effectiveness of the actions implemented by the nurse.

EOQ5.1. What findings would indicate that positive outcomes were achieved by the actions implemented by the nurse? Select all that apply.

1. Temperature is now 98.8° F (37.1° C).
2. RR is 41.
3. Pulse oximeter reads 91 percent.
4. Acrocyanosis of the feet is present.
5. The NIPS (Neonatal Infant Pain Score) is 3.

[Answers: a, b, c]

Recognizing Cues

Drew is now 3 days old and has been successfully weaned off the nasal CPAP. The nurse, when assessing Drew at the beginning of the shift, notes that Drew has a noticeable yellow tinge to her skin, especially on the face and abdomen.

RCQ6.1. What additional information (cues) would the nurse obtain at this time?

1. when the newborn last had a bath
2. the most recent bilirubin level
3. the newborn’s current vital signs
4. the newborn’s current blood glucose level

[Answer: b]

Analyzing Cues

ACQ6.1. Which cue obtained during the nurse’s assessment is of most concern?

1. newborn’s last bath at 2100 last evening
2. total bilirubin 22 mg/dL (expected <13 mg/dL)
3. current vital signs: T 99° F (37.2° C), RR 36, HR 142
4. intake and output for the past 24 hours: +56 mL with a urine output averaging 2.1 mL/kg/hr

[Answer: b]

Prioritizing Hypotheses

PHQ6.1. Based on the assessment cues, the nurse concludes the priority need for Drew at this time is to                       .

1. place Drew under bilirubin light therapy per the protocol
2. give Drew a bath this shift
3. prepare to give Drew a fluid bolus
4. obtain blood with a heel stick for the newborn screen test

[Answers: a]

Generating Solutions

GSQ6.1. Based on the identified priority need; the nurse begins to plan their actions. Place the nursing actions in the correct sequence.

1. Place eye coverings on the newborn for safety while under the phototherapy lights.
2. Place the infant under the phototherapy lights.
3. Verify the order for phototherapy lights.
4. Remove the newborn’s blankets and clothing.

1. 3, 4, 1, 2
2. 4, 3, 2, 1
3. 1, 2, 4, 3
4. 1, 2, 3, 4

[Answers a]

Taking Action

Drew has been under the bilirubin therapy lights for the past 2 hours. Drew has begun to cry, suck on her fist, and smack her lips.

TAQ6.1. What is the priority nursing intervention at this time?

1. Inform the birthing parent that Drew is showing signs of hunger and can be fed at this time.
2. Notify the health-care provider that Drew is in pain and requires medication.
3. Recheck the bilirubin level with the handheld bilirubin monitoring unit.
4. Continue bilirubin light therapy.

[Answer: a]

Evaluate Outcomes

The NICU nurse educates Toni on how best to feed Drew while the phototherapy is in place. Toni has been pumping and working with lactation support staff to try to breast-feed.

EOQ6.1 Which statement by Toni indicates the education is effective?

1. “I will need to pump my breasts every hour to ensure there is enough breast milk.”
2. “I will need to change to formula if I do not produce enough breast milk.”
3. “I will feed Drew frequently and supplement with donor milk if my breast milk supply runs out or breast-feeding is not going well.”
4. “Drew will need to remain under the bilirubin therapy lights, but I will be able to use a bottle when it is time for feeding.”

[Answer: c]