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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.
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Nurse Selma is preparing to administer ofloxacin eardrop on Catherine per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for
- A. 5-6 minutes
- B. 1 to 2 minutes
- C. 3-4 minutes
- D. 6-7 minutes
Correct Answer: B
Rationale: Warming up ofloxacin eardrops before administering is done to prevent dizziness, which can occur if a cold solution is placed in the ear. Holding the bottle with hands for about 1 to 2 minutes is usually sufficient to warm up the solution to a comfortable temperature for the patient. Warming the solution for too long, such as 5-6 minutes, may not be necessary and could potentially waste time. So, the correct duration for warming up ofloxacin eardrops is 1 to 2 minutes.
A pregnant woman presents with severe lower abdominal pain and vaginal bleeding. On examination, cervical motion tenderness and unilateral adnexal tenderness are noted, along with an adnexal mass on the affected side. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: A
Rationale: The clinical presentation of severe lower abdominal pain and vaginal bleeding in a pregnant woman, along with cervical motion tenderness, unilateral adnexal tenderness, and an adnexal mass on the affected side, is highly concerning for an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of an adnexal mass and tenderness on one side is indicative of potential tubal involvement and can mimic symptoms of pelvic inflammatory disease. Prompt evaluation and management are crucial in ectopic pregnancy to prevent life-threatening complications associated with rupture of the fallopian tube.
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.
which is the 'MAIN' goal of ethical practice of the nursing profession including the community setting?
- A. To protect the nurse and co workers
- B. To prevent reprimand from physician
- C. For the patients Family satisfaction
- D. Centered on the welfare of clients and protect their rights
Correct Answer: D
Rationale: The main goal of ethical practice in the nursing profession, including in the community setting, is centered on the welfare of clients and protecting their rights. Nurses have a professional and ethical obligation to prioritize the well-being and best interests of their patients. This includes providing high-quality care, advocating for their patients, supporting their autonomy, and upholding their rights. Ethical nursing practice is not focused on protecting the nurse or co-workers, preventing reprimand from physicians, or solely meeting the satisfaction of patients' families. Ensuring the welfare and rights of clients is the fundamental ethical principle that guides nursing practice.
Which of the following definition MOST accurately describes meningomyelocele? It is _______.
- A. Spinal cord tumor containing nerve roots.
- B. Complete exposure of the spinal cord and meninges.
- C. Herniation of spinal cord, cerebro-spinal fluid and meninges into a sac.
- D. Sac formation containing meninges and spinal fluid.
Correct Answer: C
Rationale: Meningomyelocele is a type of neural tube defect where there is a protrusion of the spinal cord, cerebrospinal fluid, and meninges through a defect in the vertebrae, forming a sac on the surface of the back. This condition occurs during fetal development when the neural tube fails to close completely, leading to the exposure of the spinal cord and its coverings. This herniation can result in a range of neurological deficits and complications, requiring surgical repair shortly after birth to prevent further damage and infections.