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A woman in active labor experiences persistent fetal malposition, with the fetus in a transverse lie presentation. What nursing intervention should be prioritized to address this abnormal labor presentation?
- A. Facilitating external cephalic version (ECV)
- B. Assisting the mother into a hands-and-knees position
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: B
Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.
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A 70- year-old has been rushed to the hospital due to bradycardia and palpitation. The physician suggested that a pacemaker be inserted to correct the symptoms. The patient voluntarily decides not to have the pacemaker Inserted. This is respected by the family. This is an example of what ethical principles
- A. Beneficence
- B. Autonomy
- C. Fidelity
- D. Justice
Correct Answer: B
Rationale: Autonomy is the ethical principle that respects an individual's right to make their own decisions about their medical treatment, even if it goes against medical advice or the preferences of others. In this case, the 70-year-old patient has voluntarily decided not to have the pacemaker inserted despite the physician's recommendation. The fact that the patient's decision is respected by the family reflects the importance of honoring the patient's autonomy and right to make decisions about their own healthcare.
Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
Which of the following statements accurately describes the role of major histocompatibility complex (MHC) molecules in antigen presentation?
- A. MHC class I molecules present exogenous antigens to CD4+ T cells.
- B. MHC class I molecules present endogenous antigens to CD8+ T cells.
- C. MHC class II molecules present endogenous antigens to CD4+ T cells.
- D. MHC class II molecules present exogenous antigens to CD8+ T cells.
Correct Answer: B
Rationale: Major histocompatibility complex (MHC) class I molecules are responsible for presenting endogenous antigens, such as viral or intracellular proteins, to CD8+ T cells. These antigens are derived from within the cell, either synthesized within the cell itself or taken up from the cytoplasm. CD8+ T cells, also known as cytotoxic T cells, recognize antigens presented by MHC class I molecules and play a key role in cell-mediated immunity by destroying infected or abnormal cells.
The staff assigned to check the fire extinguisher failed to monitor the assigned equipment. The following statements are "whereabouts" of true, EXCEPT
- A. all employees are lazy
- B. monitoring staff is important
- C. not all staff are diligent in their tasks
- D. two errors added together can be potentially devastating
Correct Answer: A
Rationale: The statement "all employees are lazy " is not a correct assertion. It is a generalization that is unfair to make about all employees. It is incorrect to assume that all employees are lazy based on the failure of a certain staff member to monitor the fire extinguisher. Making blanket statements like this can lead to further misunderstandings and negativity in the workplace. The focus should be on individual accountability, proper training, and clear communication to ensure that tasks are being diligently carried out.
You also emphasized that, "Communication must be culturally competent to be effective". Which of the following BEST reflects these statements?
- A. Listen actively to what is said
- B. Reflect on the meaning of the message
- C. Use simple, direct words
- D. Provide an appropriate environment
Correct Answer: A
Rationale: Actively listening to what is being said is a key component of effective communication that is culturally competent. By listening attentively and showing genuine interest in understanding the perspective of the speaker, you are better able to grasp the nuances of their communication style, values, and beliefs. This allows for more effective communication that takes into consideration the cultural context of the person you are communicating with. Developing active listening skills helps in building rapport, fostering understanding, and promoting mutual respect in cross-cultural interactions.