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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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A nurse is assessing a patient's pain using a pain rating scale. What action by the nurse demonstrates cultural competence in pain assessment?
- A. Assuming that the patient experiences pain similarly to other patients
- B. Using nonverbal cues to assess the patient's pain intensity
- C. Asking the patient about their cultural beliefs and preferences related to pain
- D. Administering pain medication without assessing the patient's pain level
Correct Answer: C
Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.
During theh history taking, which of the following is the MOST common symptom of Scabies that the family would report to Nurse Emma?
- A. Rashes
- B. Scaling
- C. Swelling
- D. Itchiness
Correct Answer: D
Rationale: The most common symptom of scabies that the family would report to Nurse Emma is itchiness. Scabies is a contagious skin condition caused by the Sarcoptes scabiei mite, which burrows into the skin and lays eggs, leading to intense itching, especially at night. The itching is a result of the body's allergic reaction to the mites and their waste products. While rashes, scaling, and swelling can also occur with scabies, the hallmark and most bothersome symptom experienced by individuals with scabies is the intense itchiness, making it the most common symptom reported by affected individuals or their families during the history-taking process.
One of the patients is manifesting signs and symptoms of alcohol withdrawal such as: tremors, diaphoresis, and hyperactivity. Blood pressure is 190/92 mm.Hg and pulse rate of 92 beats/min. Which of the following medications should you expect to be ordered for these patients?
- A. Lorazepam ( Ativan )
- B. Haloperidol ( Haldol )
- C. Naloxone ( Narcan )
- D. Benztropin ( Cogentin )
Correct Answer: A
Rationale: The patient is exhibiting signs and symptoms of alcohol withdrawal, such as tremors, diaphoresis, hyperactivity, elevated blood pressure, and tachycardia. Lorazepam, which is a benzodiazepine, is commonly used to manage alcohol withdrawal symptoms. It helps alleviate symptoms such as anxiety, agitation, tremors, and seizures by acting on the same brain receptors affected by alcohol. It has sedative, anxiolytic, and anticonvulsant properties which can help stabilize the patient and prevent potential complications of alcohol withdrawal, such as seizures. Haloperidol is an antipsychotic medication used for conditions like schizophrenia and acute psychosis; therefore, it would not be appropriate for alcohol withdrawal. Naloxone is used to reverse opioid overdose, and Benztropin is used to treat Parkinson's disease and extrapyramidal symptoms, so they are not indicated for alcohol
Which of the following is the PRIORITY action of the nurse for Sonny who is on Oxygen therapy?
- A. Check the flow.
- B. Connect the flow meter to the pipe in oxygen outlet
- C. Turn on the oxygen .
- D. Attach the humidifier and connecting tubing to the oxygen delivery device.
Correct Answer: A
Rationale: Checking the flow of oxygen is the priority action because it ensures that Sonny is receiving the correct amount of oxygen prescribed by the healthcare provider. Before connecting the flow meter to the oxygen outlet, turning on the oxygen, or attaching the humidifier, it is crucial to verify that the flow rate is appropriate for Sonny's condition. Monitoring and adjusting the oxygen flow will help maintain the desired oxygen saturation levels and prevent potential complications related to oxygen therapy.
During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?
- A. Increase the ambient room temperature in the operating room
- B. Administer a warming blanket or forced-air warming device
- C. Document the temperature trend in the patient's chart
- D. Continue monitoring the patient's temperature closely
Correct Answer: B
Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.