Nokea
A woman in active labor is experiencing persistent occiput posterior position despite position changes. What nursing intervention is most appropriate to facilitate fetal rotation?
- A. Encourage the mother to remain in a side-lying position.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Perform manual rotation of the fetus during vaginal examination.
Correct Answer: B
Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.
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A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
- A. Anterior uveitis
- B. Acute angle-closure glaucoma
- C. Endophthalmitis
- D. Corneal abrasion
Correct Answer: A
Rationale: The presentation described in the question is classic for anterior uveitis. Anterior uveitis is an inflammatory condition affecting the iris and ciliary body and is characterized by redness, pain, and photophobia. Slit-lamp examination typically reveals ciliary injection (redness around the iris), corneal edema, and a mid-dilated pupil with a fixed reaction to light due to inflammation causing spasm of the iris muscles. Acute angle-closure glaucoma would present with similar symptoms but would also have increased intraocular pressure, which is not mentioned in the presentation. Endophthalmitis is an infection of the intraocular cavities and would typically present with more severe symptoms, such as severe pain, vision loss, and presence of pus in the eye. Corneal abrasion would present with pain, foreign body sensation, and possibly tearing but would not cause ciliary injection or fixed pupil reaction as
While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?
- A. Present the reality situation
- B. Distract patient's attention
- C. Disagree with the patient
- D. Validate the statement
Correct Answer: B
Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.
The BEST rationale for the conduct of the program is which of the following?
- A. Ensure safe practice in the hospital
- B. Improve nursing practice in general
- C. Provide knowledge and skills to all nursing staff in IV Therapy
- D. De1iver safe and quality nursing care to patients on intravenous therapy
Correct Answer: D
Rationale: The BEST rationale for the conduct of the program is to deliver safe and quality nursing care to patients on intravenous therapy (IV). This directly ties the purpose of the program to the real-world outcome it seeks to achieve - providing optimal care for patients requiring intravenous therapy. Ensuring safe practice in the hospital (Option A) is important but it is not specific to the focus of the IV therapy program. Improving nursing practice in general (Option B) is a noble goal but the program should have a specific and targeted objective. Providing knowledge and skills to all nursing staff in IV Therapy (Option C) is essential, but the primary aim should be centered on improving patient care outcomes. Therefore, delivering safe and quality nursing care to patients on IV therapy aligns most closely with the core purpose of the program and should be the primary rationale.
Which of the following conditions is characterized by chronic hypoxemia, pulmonary hypertension, and right heart failure?
- A. Chronic obstructive pulmonary disease (COPD)
- B. Idiopathic pulmonary fibrosis (IPF)
- C. Pulmonary embolism (PE)
- D. Cor pulmonale
Correct Answer: D
Rationale: Cor pulmonale is a condition characterized by right heart failure secondary to pulmonary hypertension, which is often caused by chronic hypoxemia. Chronic hypoxemia occurs in conditions such as chronic obstructive pulmonary disease (COPD) where there is limited airflow in and out of the lungs, leading to low oxygen levels in the blood. However, the specific characteristic of pulmonary hypertension leading to right heart failure distinguishes cor pulmonale from COPD. Other conditions like idiopathic pulmonary fibrosis (IPF) and pulmonary embolism (PE) may also lead to hypoxemia but are not primarily associated with pulmonary hypertension and right heart failure as in cor pulmonale.
A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Uterine hyperstimulation
- C. Pelvic outlet obstruction
- D. Maternal exhaustion
Correct Answer: B
Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.