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During the active phase of labor, the nurse observes that the cervix is dilated to 6 cm and the contractions are regular, lasting 60 seconds each, occurring every 3 minutes. What action should the nurse take?
- A. Encourage the mother to push.
- B. Administer oxytocin to augment labor.
- C. Prepare for delivery.
- D. Continue to monitor the progress of labor.
Correct Answer: D
Rationale: During the active phase of labor, a cervical dilation of 6 cm and regular contractions lasting 60 seconds each, occurring every 3 minutes indicate good progress in labor. The nurse should continue to monitor the progress closely by assessing the mother's vital signs, fetal heart rate, and the pattern of contractions. It is important to provide support and encouragement to the mother, continue with comfort measures, and be prepared to assist with the delivery when the cervix is fully dilated. This stage of labor is focused on active dilation and effacement of the cervix, and it is not yet time for the mother to push or for the nurse to administer oxytocin to augment labor.
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Which of the following interventions is most appropriate for a patient with a tension pneumothorax?
- A. Needle decompression
- B. Chest tube insertion
- C. High-flow oxygen therapy
- D. Incentive spirometry
Correct Answer: A
Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.
A patient presents with central obesity, moon face, buffalo hump, and purple striae. Laboratory tests reveal elevated cortisol levels. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hyperthyroidism
- B. Hypothyroidism
- C. Diabetes mellitus
- D. Cushing's syndrome
Correct Answer: D
Rationale: The patient's presentation of central obesity, moon face, buffalo hump, purple striae, and elevated cortisol levels strongly suggest Cushing's syndrome. Cushing's syndrome is a disorder characterized by excessive levels of cortisol, either due to an endogenous (e.g., adrenal tumor) or exogenous (e.g., prolonged steroid use) source. The classic physical features of Cushing's syndrome include central obesity with thin extremities (truncal obesity), moon face (rounding and reddening of the face), buffalo hump (accumulation of fat between the shoulders), and purple striae (stretch marks that are wide and purple in color). In the context of the elevated cortisol levels, these clinical signs are highly indicative of Cushing's syndrome. Hyperthyroidism, hypothyroidism, and diabetes mellitus would not typically present with the specific combination of symptoms described.
A patient presents with acute onset of severe vertigo, nausea, vomiting, and nystagmus. Symptoms are worsened with head movement. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Ménière's disease
- B. Vestibular neuritis
- C. Benign paroxysmal positional vertigo (BPPV)
- D. Labyrinthitis
Correct Answer: B
Rationale: Vestibular neuritis is a condition characterized by the acute onset of severe vertigo, nausea, vomiting, and nystagmus. These symptoms are typically worsened by head movement. Vestibular neuritis is caused by inflammation of the vestibular nerve, which plays a key role in balance and spatial orientation. The classic presentation of these symptoms, along with the absence of hearing loss (which is seen in labyrinthitis), points towards vestibular neuritis as the most likely cause in this scenario. Meniere's disease presents with recurrent episodes of vertigo, hearing loss, tinnitus, and sensation of fullness in the ear. Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo triggered by changes in head position.
During the surgical procedure, the nurse notices a break in sterile technique by a member of the surgical team. What should the nurse do?
- A. Document the break in sterile technique in the surgical log
- B. Continue with the procedure and address the issue later
- C. Inform the surgeon immediately and request corrective action
- D. Report the incident to the hospital's quality assurance department
Correct Answer: C
Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.
Nurses should have knowledge about professional organization. Which of t he following is the accredited professional organization of nurses?
- A. Maternal Child Nursing
- B. Philippine Nurses Association, Inc.
- C. National leaguue of Government Nurses of the Philippines
- D. Association Nursing Service Administrators of the Phiilippines
Correct Answer: B
Rationale: The Philippine Nurses Association, Inc. (PNA) is the accredited professional organization of nurses in the Philippines. PNA is recognized as the official organization of all registered nurses in the country, dedicated to fostering high standards of nursing practice, education, and professional growth. It plays a key role in advocating for the rights and welfare of nurses, as well as promoting the advancement of the nursing profession in the Philippines. Membership in the PNA provides nurses with access to valuable resources, networking opportunities, and support for continuous professional development.