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A woman in active labor demonstrates persistent posterior fetal position, contributing to prolonged labor and severe back pain. What nursing intervention should be implemented to facilitate fetal rotation and optimize labor progress?
- A. Encourage frequent position changes, including hands-and-knees position.
- B. Administer intravenous analgesics to manage maternal discomfort.
- C. Prepare for immediate instrumental delivery.
- D. Initiate continuous fetal monitoring to assess fetal well-being.
Correct Answer: A
Rationale: Encouraging frequent position changes, including the hands-and-knees position, is the most appropriate nursing intervention in this scenario. This position is known to help rotate the baby from a persistent posterior position to an optimal anterior position for delivery. The hands-and-knees position can help take pressure off the mother's back, alleviate back pain, and facilitate the rotation of the baby's head to engage in the mother's pelvis, thus promoting labor progress. It is a non-invasive and effective way to promote fetal rotation without the need for immediate instrumental delivery or intravenous analgesics. Continuous fetal monitoring is important for assessing fetal well-being but would not directly address the issue of posterior fetal position and the associated prolonged labor.
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For this patient who is to undergo surgery (closure of the sac), what would be the PRIORITY nursing diagnosis? It is risk for __________.
- A. Activity intolerance
- B. Infection
- C. Respiration
- D. Altered growth and development
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.
The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day. Now the nurse escorts the client to the room and tells the client to stay there or be put into seclusion. The nurse is threatening to give the client an injection in order to restrain the client for inappropriate behavior. This is an example of
- A. Abuse
- B. Assault
- C. False imprisonment
- D. Battery
Correct Answer: C
Rationale: False imprisonment is the act of improperly restraining another individual against their will. In this scenario, the nurse's threat of putting the client into seclusion and administering an injection to restrain them for inappropriate behavior constitutes false imprisonment. The client is being restricted in their movement without valid reason or proper procedure. This type of action is not acceptable in healthcare settings and violates the client's rights. It is important for healthcare professionals to use appropriate de-escalation techniques and interventions to manage challenging behaviors without resorting to threats of physical restraint.
A patient admitted to the ICU develops acute gastrointestinal bleeding requiring urgent intervention. What intervention should the healthcare team prioritize to manage the patient's bleeding?
- A. Perform endoscopic hemostasis with mechanical or thermal techniques.
- B. Administer proton pump inhibitors (PPIs) to reduce gastric acid secretion.
- C. Implement strict bed rest to minimize physical exertion and bleeding risk.
- D. Recommend transfusion of fresh frozen plasma to correct coagulopathy.
Correct Answer: A
Rationale: In a patient with acute gastrointestinal bleeding requiring urgent intervention, the healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques. Endoscopy allows for direct visualization of the source of bleeding in the gastrointestinal tract, enabling targeted interventions such as clipping, cauterization, or injection of epinephrine to achieve hemostasis. This approach is effective in managing acute bleeds and can help stop the bleeding quickly, reducing the need for more invasive procedures or surgeries. Administering proton pump inhibitors (PPIs) may be considered for acid-related bleeding, but it is not the primary intervention for acute bleeding requiring urgent management. Strict bed rest may not be necessary and can increase the risk of complications such as deep vein thrombosis. Transfusion of fresh frozen plasma may be indicated if there is evidence of coagulopathy, but addressing the bleeding source should be the initial priority to
Select nurses action in keeping with principle of confidentiality
- A. Hides identity of patient
- B. Shares information from patients chart in public
- C. Keeps all matters about the patient as a secret
- D. Discuss the case of the patient with others.
Correct Answer: C
Rationale: Maintaining patient confidentiality is a foundational principle in healthcare ethics. Nurses are obligated to keep all information about patients confidential, which means not disclosing any patient-related information to unauthorized individuals. This includes refraining from discussing patient cases with others who are not directly involved in the care of the patient. Sharing patient information without consent can be a breach of trust and privacy, which can have legal and ethical implications. Therefore, in order to uphold the principle of confidentiality, nurses must keep all matters about the patient as a secret.
This global program aims to end poverty and protect the planet?
- A. Center for Disease Control
- B. Sustainable development goal
- C. Millenium development goals
- D. World health organization
Correct Answer: B
Rationale: The global program that aims to end poverty and protect the planet is known as the Sustainable Development Goals (SDGs). The SDGs were adopted by all United Nations Member States in 2015 as a universal call to action to end poverty, protect the planet, and ensure prosperity for all. The goals address a wide range of social, economic, and environmental challenges that the world faces, including poverty, hunger, health, education, gender equality, clean water, and energy. By achieving the SDGs, countries can work together to create a more sustainable and equitable world for present and future generations.