Nokea
A woman in active labor has been diagnosed with placenta previa. What is the priority nursing intervention?
- A. Prepare for immediate cesarean section.
- B. Administer intravenous oxytocin to augment labor.
- C. Insert a Foley catheter to monitor urine output.
- D. Implement bed rest and continuous fetal monitoring.
Correct Answer: A
Rationale: In the case of a woman in active labor with placenta previa, the priority nursing intervention is to prepare for an immediate cesarean section. Placenta previa is a condition in which the placenta covers part or all of the cervix, which can lead to severe bleeding during labor and delivery. The risk of hemorrhage is significant, making a cesarean section the safest option for both the mother and the baby in this situation. It is crucial to act promptly to prevent complications and ensure the well-being of both the mother and the baby. Administering intravenous oxytocin to augment labor or inserting a Foley catheter to monitor urine output would not address the immediate risk of hemorrhage associated with placenta previa. Implementing bed rest and continuous fetal monitoring may be part of the overall care plan but not the priority intervention in this urgent situation.
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While positioning the patient for surgery, the nurse notices that the patient's arms are not adequately padded. What should the nurse do?
- A. Proceed with the positioning as planned
- B. Document the observation in the patient's chart
- C. Apply soft padding to the patient's arms to prevent pressure injuries
- D. Inform the surgeon about the inadequate padding
Correct Answer: C
Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.
The first standard step in oxygen therapy that the nurse should do is________.
- A. assess client's condition
- B. gather all the equipment and supplies
- C. prepare the client for the oxygen treatment
- D. check the chart for ordered flow rate and oxygen delivery method
Correct Answer: A
Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.
Nurse Juvy's assessment reveals the following: Heart Rate is 110 beats per minute, has a vigorous cry, moves actively and with good flexion, normal skin color and bluish extremities. What would be thd APGAR score of Baby Sharon?
- A. 7 Points
- B. 5 Points
- C. 10 Points
- D. 9 Points
Correct Answer: B
Rationale: Baby Sharon's APGAR score can be determined by assessing five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criteria is given a score of 0, 1, or 2 points, with 2 being the highest score.
A patient presents with multiple, discrete, flesh-colored papules with central umbilication on the trunk and extremities. The lesions are asymptomatic and have been present for several months. Which of the following conditions is most likely responsible for this presentation?
- A. Molluscum contagiosum
- B. Basal cell carcinoma
- C. Sebaceous hyperplasia
- D. Dermatofibroma
Correct Answer: A
Rationale: Molluscum contagiosum is a viral skin infection caused by the poxvirus. It typically presents as multiple, flesh-colored, dome-shaped papules with a central umbilication (dimple or depression in the center) on the skin. These lesions are often found on the trunk and extremities and can persist for several months. Molluscum contagiosum is commonly seen in children but can also occur in adults, especially those with weakened immune systems. The lesions are usually asymptomatic but can become inflamed or itchy in some cases. Treatment options include observation, topical therapies, cryotherapy, or curettage.
A patient presents with sudden-onset severe headache, vomiting, and altered mental status. Imaging reveals a berry-shaped aneurysm at the junction of the anterior communicating artery and anterior cerebral artery. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Ischemic stroke
- B. Intracerebral hemorrhage
- C. Subdural hematoma
- D. Subarachnoid hemorrhage
Correct Answer: D
Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.