Nokea
A woman in active labor is experiencing persistent occiput posterior position despite position changes. What nursing intervention is most appropriate to facilitate fetal rotation?
- A. Encourage the mother to remain in a side-lying position.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Perform manual rotation of the fetus during vaginal examination.
Correct Answer: B
Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.
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Elmo asks the nurse to explain his condition (BPH) Which statements are CORRECT explanations by the nurse? I It blocks the urethra. II It obstructs the bladder. III. It spreads to other parts of the body. IV. It leads to urinary retention
- A. I and IV
- B. I, II and III
- C. II, III, and IV
- D. I and III
Correct Answer: A
Rationale: I. It blocks the urethra: Benign Prostatic Hyperplasia (BPH) is a condition in which the prostate gland enlarges and can squeeze the urethra, leading to urinary symptoms such as difficulty urinating. This statement correctly explains one of the effects of BPH on the urinary system.
A postpartum client with a history of breast augmentation expresses concerns about breastfeeding difficulties. What nursing intervention should be prioritized to support successful breastfeeding in this situation?
- A. Providing education on techniques to promote milk production and let-down
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding to prevent discomfort
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: D
Rationale: Referring the client to a lactation consultant for specialized support should be prioritized to support successful breastfeeding in this situation. Breast augmentation surgery may impact milk production, let-down reflex, and proper latch due to alterations in breast tissue and nerve pathways. A lactation consultant can provide individualized guidance and support to address these specific challenges. Additionally, the consultant can assist in establishing a breastfeeding plan tailored to the client's unique needs, helping to optimize the breastfeeding experience for both the mother and the baby. It is crucial to seek expert assistance in navigating any potential difficulties that may arise from breastfeeding after breast augmentation to promote successful breastfeeding outcomes.
Which of the following actions is a violation of a psychiatric patient's rights?
- A. Paranoid patient with delusions about his family is told that if he makes a will, it might not be valid.
- B. The nurse confiscated the cellphone from patient's room and tell him it is being locked in the vault.
- C. Staff members confiscated written letters done by patients addressed to local newspaper.
- D. Patient is paid minimum wage for helping in the hospital kitchen.
Correct Answer: C
Rationale: In this scenario, the action that violates a psychiatric patient's rights is option C, where staff members confiscated written letters done by patients addressed to the local newspaper. Patients have the right to communicate freely and express their thoughts and feelings through various means, such as letter-writing. Confiscating these letters is a violation of their rights to free expression and communication. It is essential to respect and uphold the rights of psychiatric patients, including their right to communicate with others.
. The patient with nephrotic syndrome is ordered corticosteroids. Who of the following are NOT ALLOWED in the patient's
- A. Parents with diabetes.
- B. Relatives with upper respiratory tract infection.
- C. Visitors with mild asthma.
- D. Personnel with allergy.
Correct Answer: A
Rationale: Patients with nephrotic syndrome who are ordered corticosteroids need to avoid close contact with individuals who have infections or illnesses, as corticosteroids can suppress the immune system and increase the risk of infections. Therefore, it is important to prioritize the safety and well-being of the patient by minimizing potential sources of infection. While diabetes itself does not pose a direct risk to the patient with nephrotic syndrome, individuals with diabetes may have a compromised immune system or be at higher risk for infections, which could potentially be transmitted to the patient. This precaution helps to minimize the risk of infection and maximize the effectiveness of the treatment for nephrotic syndrome.
A confused client who fell out of bed because side rails were not used is an example of which type of liability?
- A. Felony
- B. Battery
- C. Assault
- D. Negligence
Correct Answer: D
Rationale: Negligence is the failure to take proper care in doing something, which results in harm or injury to someone else. In this scenario, the client falling out of bed because side rails were not used indicates a lack of proper care or attention by the staff or caregiver responsible for the client. It shows a failure to protect the client from harm, which aligns with the definition of negligence. This situation does not fit the definitions of a felony, battery, or assault.