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A woman in active labor experiences prolonged and severe pain in the lower back region, along with irregular contractions. What maternal condition should the nurse consider as a potential cause of abnormal labor progress?
- A. Occiput posterior fetal position
- B. Uterine hyperstimulation
- C. Maternal exhaustion
- D. Intrauterine infection
Correct Answer: A
Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.
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A woman in active labor is experiencing a shoulder dystocia during delivery. What nursing intervention should be prioritized?
- A. Apply suprapubic pressure to dislodge the shoulder.
- B. Perform an episiotomy to facilitate delivery.
- C. Insert an oropharyngeal airway to maintain airway patency.
- D. Administer intravenous magnesium sulfate for uterine relaxation.
Correct Answer: A
Rationale: Shoulder dystocia is an obstetric emergency where one of the baby's shoulders becomes impacted behind the mother's pubic bone after the head delivers. This can lead to compression of the umbilical cord and compromise fetal oxygenation. The most critical nursing intervention in managing shoulder dystocia is applying suprapubic pressure to dislodge the impacted shoulder and allow for delivery of the baby. By gently pushing downwards on the mother's abdomen just above the pubic bone, the shoulder can be released, and the baby can be delivered successfully. This intervention should be prioritized to prevent potential complications for both the mother and the baby. Episiotomy may be considered if necessary, but it is secondary to addressing the shoulder dystocia. Oropharyngeal airway insertion and administering magnesium sulfate are not indicated in the immediate management of shoulder dystocia.
Whose responsibility is it to obtain informed consent?
- A. Nurse Manager
- B. Physician
- C. Anesthesiologist
- D. Midwife
Correct Answer: B
Rationale: The responsibility of obtaining informed consent typically falls on the physician or the healthcare provider who is performing the procedure or treatment. Informed consent is a process where the healthcare provider explains the procedure, its risks, benefits, possible alternatives, and potential outcomes to the patient or their legal representative. The patient must have a comprehensive understanding of these aspects before agreeing to the treatment. While nurses, nurse managers, anesthesiologists, midwives, and other healthcare professionals may assist in the consent process by providing information or clarifications, the ultimate responsibility lies with the physician. This is because the physician is usually the one with the expertise and knowledge about the specific procedure or treatment being performed.
A patient presents with well-demarcated, hypopigmented macules with fine scaling, affecting the trunk and proximal extremities. The patient reports a history of sun exposure and outdoor activities. Which of the following conditions is most likely responsible for this presentation?
- A. Tinea versicolor
- B. Vitiligo
- C. Pityriasis rosea
- D. Seborrheic keratosis
Correct Answer: A
Rationale: The presentation of well-demarcated, hypopigmented macules with fine scaling on the trunk and proximal extremities is classic for tinea versicolor. Tinea versicolor is a common superficial fungal infection caused by Malassezia spp., which leads to hypo- or hyperpigmented patches on the skin. The condition often occurs in individuals with increased sebum production due to factors such as hot and humid climates, sweating, and oily skin. History of sun exposure and outdoor activities is also commonly reported by patients with tinea versicolor. Treatment usually involves antifungal medications applied topically or taken orally to eliminate the fungus. Differentiating tinea versicolor from other skin conditions, such as vitiligo, pityriasis rosea, or seborrheic keratosis, is important for appropriate management.
A nurse is preparing to perform a urinary catheterization for a patient. What action should the nurse take to ensure proper insertion technique?
- A. Inserting the catheter without using sterile gloves
- B. Using aseptic technique and sterile equipment during catheter insertion
- C. Performing catheterization without using lubricating jelly
- D. Advancing the catheter rapidly to minimize patient discomfort
Correct Answer: B
Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.
When handling vaccines, the FIRST step Nurse Gabriela should do is to ________.
- A. Select the correct needle size.
- B. Check the content prior to drawing up.
- C. Reconstitute using diluent supplied.
- D. Check the vial for expiration date..
Correct Answer: D
Rationale: The first step Nurse Gabriela should do when handling vaccines is to check the vial for the expiration date. It is crucial to ensure that the vaccine has not expired before proceeding with any further steps. Administering an expired vaccine can be ineffective or even harmful to the patient. Therefore, checking the expiration date is the foundational step in the safe and proper administration of vaccines.