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A primigravida at 40 weeks gestation is in active labor. The nurse notes late decelerations on the fetal monitor tracing. What action should the nurse take first?
- A. Administer oxygen to the mother.
- B. Change the mother's position.
- C. Prepare for immediate delivery.
- D. Discontinue oxytocin infusion.
Correct Answer: D
Rationale: Late decelerations on the fetal monitor tracing indicate a potential uteroplacental insufficiency, which could be caused by decreased oxygen supply to the fetus. One common cause of late decelerations is uterine hyperstimulation due to excessive use of oxytocin. By discontinuing the oxytocin infusion, the nurse can help alleviate the stress on the fetus and decrease the likelihood of further late decelerations. This action should be prioritized before other interventions such as changing the mother's position or administering oxygen. Immediate delivery may be necessary if the fetus continues to show signs of distress despite discontinuing the oxytocin infusion.
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In writing the IR, which of the following is not included?
- A. Who was / were involved?
- B. What daily medications are given to the patient
- C. What happened?
- D. Who witnessed the incident?
Correct Answer: B
Rationale: The IR (Incident Report) typically focuses on the details surrounding an incident or event, such as what happened, who was/were involved, and who witnessed the incident. Information about daily medications given to the patient is not usually included in an incident report, unless it directly relates to the incident itself (e.g., medication error). The primary focus of an incident report is to document the incident in a clear and factual manner for record-keeping and analysis purposes.
As a nurse manager, which nursing action should do to let the staff imbibe the culture of quality at the health center?
- A. Become a role model
- B. Reprimand every now and then
- C. Frequent meetings
- D. Allow them to read books
Correct Answer: A
Rationale: As a nurse manager, the most effective way to let the staff imbibe the culture of quality at the health center is to become a role model. Leading by example is a powerful way to influence behavior and attitudes within a team. By demonstrating a commitment to quality in your own work, behavior, and decision-making, you set a positive example for your staff to follow. This proactive approach creates a culture of quality that is more likely to be embraced by the team as they see it being consistently demonstrated by their leader. This can result in improved staff morale, motivation, and overall performance in delivering quality care to patients. Additionally, being a role model fosters trust and respect among the staff, which is essential for building a strong team dynamic centered around quality healthcare delivery.
The INITIAL priority assessment performed by the nurse, when admitting a patients the unit after abdominal surgery is to check for ______.
- A. surgical site for drainage and hemorrhage
- B. skin color and temperature
- C. responsiveness to painful stimuli and noise
- D. respiratory function and airway
Correct Answer: D
Rationale: When admitting a patient to the unit after abdominal surgery, the initial priority assessment performed by the nurse should focus on assessing the patient's respiratory function and airway. This is crucial because post-surgical patients are at risk for complications such as respiratory depression, atelectasis, and airway obstruction. Monitoring the patient's breathing pattern, oxygen saturation levels, and ensuring a patent airway are essential in preventing respiratory distress or failure. Prompt assessment and intervention in this area can help prevent respiratory complications and ensure the patient's safety and well-being. Once the patient's respiratory status is stable, the nurse can then proceed to assess other aspects such as the surgical site, skin color, temperature, and responsiveness to stimuli.
Because of the scarcity of nurses in the hospital settings, different service delivery models were proposed. Which Situation represents the primary nursing care delivery model?
- A. The nursing aide is assigned to make beds and other errands while the nurse is to give medications.
- B. The nurse develops a plan of care for patients and collaborates with other team members.
- C. The nurse performs all tasks needed by the individual patient to optimize health .
- D. The nurse provides care to 4 patients while the nursing aide is to care for 2 patients.
Correct Answer: C
Rationale: The primary nursing care delivery model is represented by option C, where the nurse performs all tasks needed by the individual patient to optimize health. In this model, the nurse is responsible for coordinating and providing comprehensive care to a specific group of patients throughout their stay. The primary nurse establishes a close relationship with the patient and takes accountability for their care, ensuring continuity, communication, and personalized attention. This approach emphasizes the importance of the nurse-patient relationship and holistic care delivery, which can lead to improved patient outcomes and satisfaction.
A patient presents with sudden-onset severe lower abdominal pain, nausea, vomiting, and inability to pass urine. On physical examination, there is suprapubic tenderness and a palpable bladder. What is the most likely diagnosis?
- A. Acute pyelonephritis
- B. Acute urinary retention
- C. Renal colic
- D. Bladder cancer
Correct Answer: B
Rationale: The patient's presentation with sudden-onset severe lower abdominal pain, nausea, vomiting, inability to pass urine, suprapubic tenderness, and a palpable bladder is classic for acute urinary retention. Acute urinary retention is a urological emergency characterized by the sudden inability to pass urine due to the inability to empty the bladder completely. The palpable bladder on physical examination indicates significant bladder distension. This condition can be caused by multiple factors such as bladder outlet obstruction, neurogenic causes, or medications affecting bladder function. Prompt intervention is necessary to relieve the bladder distension, alleviate symptoms, and prevent complications like bladder rupture.