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A woman in active labor experiences irregular and ineffective uterine contractions, resulting in prolonged cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
- A. Encourage the mother to ambulate and change positions frequently.
- B. Administer intravenous opioids to enhance pain relief and relaxation.
- C. Initiate continuous electronic fetal monitoring to assess fetal well-being.
- D. Prepare for immediate cesarean section due to labor dystocia.
Correct Answer: A
Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.
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A patient presents with progressive weakness, muscle atrophy, and fasciculations, primarily involving the upper and lower extremities. Over time, the patient develops difficulty swallowing and breathing. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Parkinson's disease
- B. Guillain-Barré syndrome (GBS)
- C. Amyotrophic lateral sclerosis (ALS)
- D. Myasthenia gravis
Correct Answer: C
Rationale: The symptoms described are classic for amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. ALS is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and atrophy. Patients typically present with weakness, muscle atrophy, fasciculations (muscle twitching), and eventually develop difficulty swallowing and breathing due to involvement of the muscles responsible for these functions. Parkinson's disease (Choice A) is a neurodegenerative disorder characterized by tremors, rigidity, and bradykinesia but does not typically present with muscle atrophy or fasciculations as described in the case. Guillain-Barré syndrome (GBS) (Choice B) is an acute inflammatory condition affecting peripheral nerves, leading to ascending paralysis, which is usually reversible. Myasthenia gravis (Choice D) is an autoimmune disorder that affects neu
A patient presents with a sensation of fullness and pressure in the left ear, along with hearing loss and occasional tinnitus. Otoscopic examination reveals a retracted tympanic membrane with decreased mobility on pneumatic otoscopy. Which of the following conditions is most likely responsible for this presentation?
- A. Acute otitis media
- B. Otitis externa
- C. Serous otitis media (otitis media with effusion)
- D. Cholesteatoma
Correct Answer: C
Rationale: The presentation described with a sensation of fullness and pressure in the left ear, along with hearing loss and occasional tinnitus, and the findings of a retracted tympanic membrane with decreased mobility on pneumatic otoscopy are most consistent with serous otitis media, also known as otitis media with effusion (OME). OME is characterized by the presence of non-infected fluid in the middle ear space, leading to symptoms such as ear fullness, hearing loss, and occasionally tinnitus.
A woman in active labor is receiving intravenous oxytocin for labor augmentation. What nursing intervention is essential to prevent oxytocin-induced uterine hyperstimulation?
- A. Monitor maternal vital signs every 2 hours.
- B. Increase the oxytocin infusion rate gradually.
- C. Administer intravenous fluids rapidly.
- D. Encourage the mother to ambulate regularly.
Correct Answer: B
Rationale: When a woman in active labor is receiving intravenous oxytocin for labor augmentation, it is essential to increase the oxytocin infusion rate gradually to prevent oxytocin-induced uterine hyperstimulation. Uterine hyperstimulation can lead to complications such as fetal distress, uterine rupture, and postpartum hemorrhage. By increasing the oxytocin infusion rate gradually, the uterus has more time to adapt to the medication and reduces the risk of hyperstimulation. It is crucial for the healthcare provider to carefully monitor the woman's response to oxytocin and adjust the infusion rate as needed to ensure safe and effective labor augmentation. Monitoring for signs of uterine hyperstimulation, such as persistent contractions close together or excessive uterine activity, is crucial in preventing complications and ensuring the well-being of both the mother and baby.
Which of the following historical data MOST probably led to a post-traumatic stress disorder?
- A. Unstable relationship with ex-fiancee.
- B. No gang-relationship with peers
- C. Suicide of her mother
- D. Dropping out of school.
Correct Answer: C
Rationale: The suicide of her mother is the most probable historical data that led to post-traumatic stress disorder. Experiencing the suicide of a close family member, especially a parent, can be an extremely traumatic event that can have long-lasting psychological effects. Witnessing or dealing with such a tragic loss can lead to feelings of helplessness, depression, guilt, and intense emotional distress, all of which are common in individuals with post-traumatic stress disorder (PTSD). This significant and distressing event could have a profound impact on the individual's mental health and well-being, contributing to the development of PTSD symptoms such as intrusive memories, avoidance behaviors, negative mood alterations, and changes in arousal or reactivity.
A patient admitted to the ICU develops acute myocardial infarction (MI) with ST-segment elevation on electrocardiogram (ECG). What intervention should the healthcare team prioritize to manage the patient's MI?
- A. Perform emergent coronary angiography for revascularization.
- B. Administer fibrinolytic therapy to restore coronary blood flow.
- C. Implement strict bed rest to minimize cardiac workload.
- D. Recommend beta-blocker medications to reduce myocardial oxygen demand.
Correct Answer: A
Rationale: In a patient with acute myocardial infarction (MI) presenting with ST-segment elevation on ECG, the healthcare team should prioritize performing emergent coronary angiography for revascularization. This intervention, also known as primary percutaneous coronary intervention (PCI), involves opening up the blocked coronary artery responsible for the MI. Timely reperfusion of the affected artery is crucial in reducing myocardial damage and improving outcomes in acute MI patients. PCI is considered the preferred method for revascularization in patients with ST-segment elevation MI, as it has been shown to be more effective and associated with better outcomes compared to fibrinolytic therapy.