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A woman in active labor is diagnosed with an obstetric emergency requiring immediate delivery. What is the priority nursing action?
- A. Notifying the healthcare provider
- B. Preparing the delivery room for immediate birth
- C. Administering intravenous fluids rapidly
- D. Facilitating continuous fetal monitoring
Correct Answer: B
Rationale: In the situation of an obstetric emergency requiring immediate delivery, the priority nursing action is to prepare the delivery room for the birth. This involves ensuring that all necessary supplies and equipment are readily available, the bed is adjusted to the appropriate position, and the healthcare team is prepared to assist with the birth. By expeditiously preparing the delivery room, the healthcare team can facilitate a safe and timely delivery for both the mother and the baby. Notifications to the healthcare provider, administering intravenous fluids, and continuous fetal monitoring can be done simultaneously but preparing the delivery room takes precedence to ensure a prompt response to the emergent situation.
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A postpartum client who delivered preterm expresses concern about breastfeeding her premature infant. What nursing intervention should be prioritized to support successful breastfeeding in this situation?
- A. Providing education on strategies for initiating and maintaining milk supply
- B. Recommending the use of supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to postpone breastfeeding until the infant reaches full term
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: A
Rationale: Providing education on strategies for initiating and maintaining milk supply should be prioritized to support successful breastfeeding in this situation. Preterm infants can benefit significantly from breast milk due to its unique composition that supports their growth and development. Educating the client on techniques such as pumping to establish and maintain milk supply, proper latching techniques, and understanding the benefits of breastfeeding for preterm infants can help alleviate her concerns and increase her confidence in breastfeeding her premature infant. Additionally, promoting skin-to-skin contact and frequent feedings can also help stimulate milk production and foster bonding between the mother and infant. Encouraging and supporting the client with evidence-based information will be crucial in promoting successful breastfeeding outcomes for the preterm infant.
A patient is prescribed an angiotensin-converting enzyme (ACE) inhibitor for the management of hypertension. Which adverse effect should the nurse monitor closely in the patient?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypotension Theatre Nursing
Correct Answer: A
Rationale: When a patient is prescribed with an angiotensin-converting enzyme (ACE) inhibitor for managing hypertension, the nurse should monitor closely for signs of hyperkalemia. ACE inhibitors can affect the renin-angiotensin-aldosterone system, leading to decreased aldosterone secretion and impaired potassium excretion by the kidneys. As a result, potassium levels in the blood may increase, leading to hyperkalemia.
A patient with a history of coronary artery disease is prescribed aspirin for antiplatelet therapy. Which information is important for the nurse to include in patient education about aspirin therapy?
- A. "Take aspirin with a full glass of milk to minimize gastrointestinal upset."
- B. "Avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) while taking aspirin."
- C. "Discontinue aspirin therapy if you develop a fever."
- D. "Take aspirin on an empty stomach for better absorption."
Correct Answer: B
Rationale: The correct information for the nurse to include in patient education about aspirin therapy is to advise the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) while taking aspirin. NSAIDs can increase the risk of gastrointestinal bleeding when taken along with aspirin, which is already a blood-thinning medication due to its antiplatelet effects. Patients with coronary artery disease are typically prescribed aspirin for its antiplatelet properties to prevent blood clot formation in the arteries. Avoiding NSAIDs will help reduce the risk of gastrointestinal complications and ensure the effectiveness of aspirin therapy in preventing cardiovascular events. Taking aspirin with a full glass of milk (Option A) is not a necessary instruction for aspirin therapy. Discontinuing aspirin therapy if a patient develops a fever (Option C) is not a standard practice unless advised by a healthcare provider. Taking aspir
Upon further assessment, you notices that she had any scratches on her right ankle, a resulting infection, and cellulitis. When you asked her about the scratches, the patient states, "Oh, my cat might have been using my leg as a scratiching post again and I did not even feel it." Which diabetic complicatons suspect the patient to have?
- A. Neuropathy
- B. Retinopathy
- C. Macroangiopathy
- D. Nephropathy
Correct Answer: A
Rationale: The patient's lack of sensation in her right leg, allowing her cat to scratch her without her noticing, is indicative of neuropathy. Neuropathy is a common diabetic complication characterized by nerve damage that can result in loss of sensation or altered sensation in different parts of the body, including the extremities. In this case, neuropathy has likely affected the patient's right lower extremity, leading to her inability to feel the cat scratching her leg and resulting in the unnoticed scratches, infection, and subsequent cellulitis.
A patient presents with multiple grouped vesicles on an erythematous base, affecting the genital area. The patient reports a history of similar lesions in the past, occurring during periods of stress. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex genitalis
- B. Genital warts (condyloma acuminata)
- C. Syphilis (chancre)
- D. Molluscum contagiosum
Correct Answer: A
Rationale: The presentation described, involving multiple grouped vesicles on an erythematous base in the genital area, is classic for herpes simplex genitalis. This condition is caused by the herpes simplex virus (HSV) and is characterized by recurrent outbreaks of painful vesicles in the genital or perianal area. The history of similar lesions occurring during periods of stress is also suggestive of herpes simplex virus reactivation. Genital warts (condyloma acuminata) typically present as painless, fleshy growths in the genital area caused by human papillomavirus (HPV). Syphilis manifests as a painless ulcer known as a chancre, which is not described in the presentation. Molluscum contagiosum presents with pearly, dome-shaped papules with central umbilication, rather than vesicles.