Nokea
A woman in active labor is experiencing umbilical cord prolapse. What is the priority nursing action?
- A. Elevating the mother's hips to relieve pressure on the cord
- B. Preparing for immediate cesarean section
- C. Administering intravenous fluids rapidly
- D. Applying external fetal monitoring to assess fetal heart rate
Correct Answer: B
Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.
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A patient presents with multiple, flesh-colored, papular lesions with a central dell on the face and trunk. The lesions have a tendency to bleed upon minor trauma and have been increasing in number over time. Which of the following conditions is most likely responsible for this presentation?
- A. Basal cell carcinoma
- B. Squamous cell carcinoma
- C. Seborrheic keratosis
- D. Actinic keratosis
Correct Answer: A
Rationale: The presentation described in the question is classic for basal cell carcinoma (BCC). BCC typically presents as multiple, flesh-colored, papular lesions with a central dell (resembling a pearl-like appearance) on sun-exposed areas such as the face and trunk. These lesions are known to bleed easily upon minor trauma and tend to increase in number over time. BCC is the most common type of skin cancer, often triggered by sun exposure. On the other hand, seborrheic keratosis (choice C) presents as benign, pigmented, stuck-on, waxy, or warty lesions with a rough surface, true bumpy appearance. Squamous cell carcinoma (choice B) usually presents as a scaly, erythematous, rapidly growing nodule, ulcer, or plaque. Actinic keratosis (choice D) presents as rough, scaly patches on sun-exposed areas that can progress to
A patient presents with a painless, slowly enlarging mass in the right neck, just above the clavicle. Fine-needle aspiration cytology reveals clusters of polygonal cells with clear cytoplasm and centrally located nuclei. Which of the following conditions is most likely responsible for this presentation?
- A. Parathyroid adenoma
- B. Thyroglossal duct cyst
- C. Lymphadenopathy
- D. Thyroid carcinoma
Correct Answer: A
Rationale: The described presentation of a painless, slowly enlarging mass in the right neck just above the clavicle, along with the cytology findings of clusters of polygonal cells with clear cytoplasm and centrally located nuclei, is classic for parathyroid adenoma. Parathyroid adenomas are benign tumors arising from one of the parathyroid glands, which are typically located in the neck region close to the thyroid gland. The clear cytoplasm and centrally located nuclei of the cells are characteristic histological features of parathyroid adenomas. This condition can often lead to hyperparathyroidism, characterized by increased levels of parathyroid hormone (PTH) and hypercalcemia. Treatment involves surgical removal of the adenoma.
A retired nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the, the nurse would probably be covered by
- A. Her homeowner's insurance
- B. National Care Act
- C. Her automobile insurance
- D. The Good Samaritan Law
Correct Answer: D
Rationale: The Good Samaritan Law offers legal protection to individuals who voluntarily provide assistance at the scene of an emergency or accident. These laws vary by state, but generally, they grant immunity from civil liability for the individual providing aid as long as they act in good faith and without expectation of compensation. In this case, the retired nurse who stopped to help in the emergency at the scene of an accident would likely be covered by the Good Samaritan Law, protecting her from being sued by the injured party for any unintended consequences of her efforts to assist.
A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?
- A. Encouraging the client to ambulate to promote bowel function
- B. Providing a heating pad to alleviate abdominal discomfort
- C. Notifying the healthcare provider immediately
- D. Administering a laxative to promote bowel evacuation
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.
A woman in active labor experiences a prolonged latent phase, characterized by irregular contractions and minimal cervical dilation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Fetal malposition
- C. Maternal anxiety
- D. Fetal macrosomia
Correct Answer: A
Rationale: Maternal dehydration can lead to a prolonged latent phase in labor due to inadequate hydration affecting the progress of labor. Dehydration can cause decreased blood volume, leading to poor uterine perfusion and inefficient uterine contractions. It also contributes to reduced amniotic fluid volume and can lead to maternal exhaustion. Therefore, assessment and correction of maternal hydration status are crucial in improving labor patterns and preventing complications during labor and delivery.