Nokea
A woman in active labor presents with a prolonged latent phase, characterized by irregular and ineffective contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal hypotension
- B. Maternal anxiety
- C. Fetal macrosomia
- D. Maternal fever
Correct Answer: B
Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.
You may also like to solve these questions
Nurse Pat promised to a post- surgical patient, that she would come back to assist in his of ambulation after carrying out the physician's order. This follows the principle
- A. beneficence
- B. autonomy
- C. justice
- D. fidelity
Correct Answer: D
Rationale: Fidelity is a principle in nursing ethics that pertains to being faithful or loyal to commitments and promises made to patients. When Nurse Pat promised to come back to assist in the patient's ambulation after carrying out the physician's order, she is demonstrating fidelity by fulfilling her commitment to the patient's care. This principle helps build trust between the nurse and the patient, ensuring continuity and quality of care.
Which of the following tools used by nurses in the community setting for assessing health needs and problems of families that is similar to family coping index
- A. Nursing theories
- B. Vitals statistics
- C. Case study
- D. Nursing diagnosis
Correct Answer: D
Rationale: Nursing diagnosis is the tool used by nurses in the community setting for assessing health needs and problems of families that is similar to the family coping index. Nursing diagnosis involves systematic assessment of a patient's health status, analysis of data, and identification of actual or potential health problems. Just like the family coping index, nursing diagnosis helps nurses to identify key issues and develop a plan of care that addresses the specific needs and challenges faced by the family. This process allows nurses to provide individualized care that supports the family in coping with their health needs and improving their overall well-being.
A postpartum client exhibits signs of severe dehydration, including dry mucous membranes, decreased skin turgor, and oliguria. Which nursing action is most appropriate?
- A. Administering intravenous fluids as ordered
- B. Offering oral rehydration solutions
- C. Providing education on fluid intake
- D. Notifying the healthcare provider immediately
Correct Answer: A
Rationale: Administering intravenous fluids as ordered is the most appropriate nursing action for a postpartum client exhibiting signs of severe dehydration. Severe dehydration, as indicated by dry mucous membranes, decreased skin turgor, and oliguria, requires immediate intervention to restore fluid balance effectively. Intravenous fluids deliver fluids directly into the bloodstream, ensuring rapid rehydration and addressing the critical situation promptly. Offering oral rehydration solutions may not be sufficient to address severe dehydration, and providing education on fluid intake can be important for prevention but is not the immediate priority in this scenario. Notifying the healthcare provider is essential, but initiating intravenous fluids promptly is crucial in managing severe dehydration.
In assessing the health condition of school children which of the following would be the finding common to this age group?
- A. Cancer and other malignancies
- B. Anemia and other blood disorders
- C. Lice and parasites
- D. Fractures and injuries
Correct Answer: B
Rationale: In assessing the health condition of school children, anemia and other blood disorders are more commonly observed in this age group compared to cancer, lice, parasites, fractures, and injuries. Anemia is a common health issue among children due to various factors such as poor nutrition, iron deficiency, and infections. Regular screening for anemia is important in school-age children to prevent long-term complications and to promote their overall health and well-being. While cancer, lice, parasites, fractures, and injuries can also occur in school children, anemia and blood disorders are more prevalent in this age group.
A patient presents with bone pain, fatigue, and frequent infections. Laboratory tests reveal pancytopenia, hypocellular bone marrow, and absence of reticulocytes. Which of the following conditions is most likely to cause these findings?
- A. Aplastic anemia
- B. Iron deficiency anemia
- C. Myelodysplastic syndrome (MDS)
- D. Acute lymphoblastic leukemia (ALL)
Correct Answer: A
Rationale: Aplastic anemia is a condition characterized by a reduction in the number of all three blood cell types: red blood cells, white blood cells, and platelets. The patient's presentation of bone pain, fatigue, frequent infections, pancytopenia (decreased counts of all blood cell types), hypocellular bone marrow (reduced cellularity in the bone marrow), and absence of reticulocytes is indicative of aplastic anemia.