Nokea
A woman in active labor demonstrates persistent occiput posterior fetal position, leading to prolonged labor and severe back pain. What nursing intervention should be prioritized to facilitate fetal rotation and optimize labor progress?
- A. Assisting the mother into a hands-and-knees position
- B. Administering intravenous opioids for pain relief
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: A
Rationale: Assisting the mother into a hands-and-knees position should be prioritized to facilitate fetal rotation and optimize labor progress in the case of persistent occiput posterior fetal position. This position helps in promoting fetal rotation to a more favorable position for delivery by allowing the baby's head to move into the anterior position. It can help alleviate back pain and may help reduce the duration of labor. This simple maneuver can sometimes correct the malposition without the need for interventions like instrumental delivery. It is a non-invasive and effective technique that can be easily implemented by healthcare providers to support the progression of labor.
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Ella's states'I wish I were dead . I cannot stand anymore not having lory around." ; your most appropriate Nursing action would be:
- A. Do nothing because Ella will not do it
- B. Stay with Ella
- C. Refer Ella to your supervisor
- D. Explore Ella's feelings
Correct Answer: D
Rationale: It is important for the nurse to explore Ella's feelings further when she expresses thoughts of wishing to be dead and struggling with not having someone around. These statements indicate that Ella may be experiencing emotional distress or depression, which require immediate attention. By exploring Ella's feelings, the nurse can assess the severity of her emotional state, provide appropriate support, and potentially prevent any harm or self-harm. It is crucial to address and validate her emotions, as well as to initiate necessary interventions to ensure her safety and well-being.
Charting are important documents that are used in court proceedings a Nurse Chona should take note that the following entry recorded would be MOST defensible in court?
- A. Large bruises on thigh upon assessment.
- B. Patient fell out of bed when reaching out for medication.
- C. Burn on the back area observed upon auscultation.
- D. Patient drunk when seen in the Emergency Room.
Correct Answer: A
Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.
A patient with heart failure is prescribed digoxin. Which electrolyte imbalance increases the risk of digoxin toxicity?
- A. Hyperkalemia
- B. Hypernatremia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: C
Rationale: Hypokalemia (low levels of potassium) increases the risk of digoxin toxicity. This is because digoxin competes with potassium for binding sites on the sodium-potassium ATPase pump in the cell membrane. When potassium levels are low, there is an increased binding of digoxin to these pumps, leading to enhanced entry of calcium into the cells. This can result in an increased intracellular calcium concentration, leading to digoxin toxicity and potential cardiac arrhythmias. Therefore, monitoring and correcting potassium levels is crucial in patients prescribed digoxin to reduce the risk of toxicity.
Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is _____.
- A. increasing pulse and decreasing blood pressure
- B. altered mental status and level of consciousness
- C. dizziness and increasing respiratory rate
- D. Cool, clammy skin, and pale mucous membranes
Correct Answer: A
Rationale: Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is an increasing pulse and decreasing blood pressure. Hypovolemia is a condition where there is a decreased volume of circulating blood in the body, often characterized by fluid loss such as through bleeding. As blood volume decreases, the heart rate increases in an attempt to maintain adequate perfusion to organs and tissues. This results in an elevated pulse rate. Additionally, as the blood volume decreases, the blood pressure may drop due to the reduced amount of blood being pumped around the body. Therefore, monitoring for an increasing pulse and decreasing blood pressure is crucial in detecting hypovolemia early, allowing for prompt intervention to prevent further complications.
Which of the following dental conditions is characterized by a localized accumulation of pus within the periodontal tissues, often associated with deep periodontal pockets?
- A. Dental caries
- B. Gingivitis
- C. Periodontitis
- D. Dental abscess
Correct Answer: D
Rationale: A dental abscess is a localized accumulation of pus within the periodontal tissues, often associated with deep periodontal pockets. This condition typically arises from bacterial infection in the tooth pulp (periapical abscess) or in the periodontal tissues (periodontal abscess). The pus accumulation leads to localized swelling, pain, and tenderness in the affected area. Treatment usually involves draining the abscess and addressing the underlying infection through root canal therapy, periodontal treatment, or extraction, depending on the extent of the infection. It is important to seek prompt dental care to prevent potential complications as abscesses can lead to severe pain, systemic infection, and even tooth loss if left untreated.