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A woman in active labor demonstrates signs of uterine inertia, with weak and irregular contractions contributing to slow cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
- A. Administering intravenous oxytocin to augment contractions
- B. Preparing for immediate cesarean section
- C. Facilitating maternal rest and hydration
- D. Performing an emergency manual rotation of the fetus
Correct Answer: A
Rationale: In cases of uterine inertia, where weak and irregular contractions are causing slow cervical dilation during labor, administering intravenous oxytocin can help augment contractions and stimulate more effective progress. Oxytocin is a hormone that naturally stimulates uterine contractions and is commonly used in clinical settings to induce or enhance labor. By increasing the strength and frequency of contractions, oxytocin can help address uterine inertia and promote efficient cervical dilation to facilitate the progress of labor. It is important to monitor the response to oxytocin carefully to avoid complications such as hyperstimulation of the uterus, which can lead to fetal distress.
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You should check the patient for suspect disturbed thought processes related to depressed metabolism and altered cardiovascular and respiratory status. What is the rationale for orienting the patient to time, place, date, and events?
- A. Shows improved cognitive functioning
- B. Provides reality orientation to patient
- C. Permits evaluation of effectiveness of treatment
- D. Let the patient identify the time, place, date, and events correctly
Correct Answer: B
Rationale: The correct answer is B: Provides reality orientation to patient. Orienting the patient to time, place, date, and events helps them stay connected to reality and improves their awareness of their surroundings. This is crucial in assessing their cognitive functioning and ensuring they are grounded in the present moment. By providing reality orientation, healthcare providers can better understand the patient's current mental state and address any potential confusion or disorientation. This approach aids in establishing a therapeutic environment and enhances the patient's overall well-being. Choices A, C, and D do not capture the essence of reality orientation and its significance in maintaining the patient's mental clarity and connection to the present moment.
A patient with a history of stroke is prescribed aspirin and clopidogrel for dual antiplatelet therapy. Which nursing intervention is essential for preventing bleeding complications in this patient?
- A. Administering proton pump inhibitors (PPIs) concomitantly
- B. Encouraging increased fluid intake
- C. Monitoring for signs of thrombocytopenia
- D. Providing education on fall prevention measures
Correct Answer: A
Rationale: The correct answer is A: Administering proton pump inhibitors (PPIs) concomitantly. Aspirin and clopidogrel can increase the risk of gastrointestinal bleeding. PPIs help reduce this risk by decreasing gastric acid production. Therefore, administering PPIs with dual antiplatelet therapy is essential for preventing bleeding complications. Encouraging increased fluid intake (B) may not directly address the risk of bleeding. Monitoring for signs of thrombocytopenia (C) is important but may not directly prevent bleeding in this case. Providing education on fall prevention measures (D) is important for overall safety but does not directly address bleeding risks associated with dual antiplatelet therapy.
Informed consent in this study will be obtained by Myra from the
- A. six participants only
- B. parents only
- C. six participants and available relative
- D. six participants and their parents
Correct Answer: D
Rationale: The correct answer is D because informed consent should be obtained from both the participants and their parents to ensure full understanding and agreement from all parties involved. This is crucial when working with minors to protect their rights and ensure ethical standards are met. Choice A is incorrect as it excludes parental consent, which is necessary for minors. Choice B is also incorrect as it neglects the participants' direct involvement in consenting to participate. Choice C is incorrect because it only includes available relatives, which may not be legally authorized to provide consent on behalf of the participants.
The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?
- A. Symphysis pubis
- B. Midline
- C. Umbilicus
- D. Sides of the abdomen
Correct Answer: C
Rationale: The correct answer is C: Umbilicus. The nurse begins assessing the uterine fundus at the level of the umbilicus as it is a standard reference point for postpartum fundal height measurement. This location allows for consistency and accuracy in tracking the descent of the uterus back into the pelvic cavity. Starting at the umbilicus also helps in monitoring the involution process and prevents potential errors in fundal height assessment.
Symphysis pubis (A) is too low and not typically used as a reference point for uterine fundal assessment. Midline (B) is vague and does not provide a specific anatomical landmark. Sides of the abdomen (D) do not give a standardized starting point for measuring the uterine fundus, leading to potential variability in assessment.
When communicating with a patient who is hard of hearing, what is an essential consideration for the nurse?
- A. Speak loudly to ensure the patient can hear.
- B. Avoid using visual aids or gestures.
- C. Position oneself at eye level and speak clearly and slowly.
- D. Speak quickly to minimize the time spent on communication.
Correct Answer: C
Rationale: The correct answer is C because positioning oneself at eye level helps the patient see the nurse's facial expressions and lip movements, aiding in communication. Speaking clearly and slowly allows the patient to better understand. Speaking loudly can distort sound and may not be necessary. Avoiding visual aids or gestures limits communication channels. Speaking quickly can overwhelm the patient and hinder comprehension.