After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?
- A. "I will wipe the area from front to back using blotting motion "
- B. "I will put ice packs on the site 15 minutes once a day for 3 to 4 days"
- C. "Before bedtime, I will do a cold water sitz bath"
- D. "I'll use sudsy water to clean the episiotomy"
Correct Answer: A
Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.
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The inappropriate use of restraints or seclusion is considered which form of intentional tort?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Causation
Correct Answer: A
Rationale: The inappropriate use of restraints or seclusion is considered a form of false imprisonment, which is an intentional tort. False imprisonment occurs when someone intentionally restricts another person's freedom of movement without their consent or legal justification. In healthcare settings, using restraints or seclusion inappropriately on a patient can constitute false imprisonment if it is not done for the safety of the patient or others and without proper authorization. This act can lead to legal consequences and liabilities for healthcare providers.
The labor progress and the physician performed amniotomy. Nurse Hope should FIRST assess tor _______.
- A. bladder distention
- B. maternal blood pressure
- C. cervical dilatation
- D. fetal heart rate (FHR) pattern
Correct Answer: D
Rationale: Following an amniotomy procedure during labor, Nurse Hope's priority should be to assess the fetal heart rate (FHR) pattern. This assessment is crucial to ensure the well-being and safety of the fetus. Changes in the FHR can provide valuable information about fetal distress or complications, allowing for timely interventions if needed. Monitoring the FHR pattern is a standard practice during labor and delivery to track the fetus's response to the changes in uterine activity. Therefore, assessing the FHR pattern should be the first priority after a labor progress and amniotomy.
Aside from atttending seminars which of the following informal continuing education programss should the nurse engaged herself EXCEPT:
- A. Attendding professional conventions
- B. Webinars
- C. Symposium
- D. Doing reseach as academic requirement
Correct Answer: D
Rationale: While attending professional conventions, webinars, and symposiums are all valuable informal continuing education programs that can help nurses stay updated with the latest trends and developments in the field, doing research as an academic requirement is not typically considered an informal continuing education activity. Research is a formal process that involves structured methodologies and academic rigor. While research may be a valuable activity for professional growth, it is not usually classified under informal continuing education programs that nurses engage in to supplement their knowledge and skills.
A patient presents with sudden-onset, severe eye pain, headache, nausea, and vomiting. On examination, the affected eye appears red, with a steamy cornea and mid-dilated, non-reactive pupil. Which of the following conditions is most likely responsible for this presentation?
- A. Acute angle-closure glaucoma
- B. Central retinal artery occlusion
- C. Optic neuritis
- D. Corneal ulcer
Correct Answer: A
Rationale: The clinical presentation described is highly suggestive of acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. The red eye, steamy cornea (due to corneal edema), and mid-dilated, non-reactive pupil (from the unopposed force of the dilator muscle) are classic findings in acute angle-closure glaucoma. The increase in intraocular pressure compromises blood flow to the eye, leading to symptoms of blurred vision and possible visual loss. Immediate management usually involves lowering intraocular pressure with medications or surgical intervention to prevent vision loss. Central retinal artery occlusion, optic neuritis, and corneal ulcer typically present with different clinical features and are not consistent with the described presentation.
A postpartum client who delivered via cesarean section expresses concerns about breastfeeding difficulties and worries about insufficient milk supply. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing education on techniques to improve latch and milk transfer
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding to prevent discomfort
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: A
Rationale: The correct nursing intervention to prioritize in this situation is providing education on techniques to improve latch and milk transfer. Cesarean section deliveries can sometimes pose challenges for breastfeeding initiation, but with proper education and support, many women can successfully breastfeed following a C-section. By teaching the client techniques to improve latch and milk transfer, the nurse can help address the client's concerns about breastfeeding difficulties and worries about insufficient milk supply. This proactive approach empowers the client to overcome breastfeeding challenges and increase their confidence in their ability to breastfeed successfully. Referring the client to a lactation consultant for specialized support may also be beneficial, but providing initial education on latch and milk transfer is crucial in this early postpartum period. Recommending formula feedings or discouraging breastfeeding may not be appropriate interventions, as they can affect the establishment of breastfeeding and undermine the client's breastfeeding goals.
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