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A postpartum client exhibits signs of deep vein thrombosis (DVT), including calf pain, swelling, and warmth. Which nursing action is most appropriate?
- A. Applying warm compresses to the affected calf
- B. Encouraging ambulation to promote circulation
- C. Notifying the healthcare provider immediately
- D. Administering anticoagulant medication as ordered
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a serious condition that requires prompt medical intervention. The presence of calf pain, swelling, and warmth in a postpartum client are concerning signs of a potential DVT. By notifying the healthcare provider immediately, appropriate diagnostic tests, such as ultrasound imaging, can be ordered to confirm the diagnosis. Timely treatment with anticoagulant medication can then be initiated to prevent complications such as pulmonary embolism. Applying warm compresses or encouraging ambulation may exacerbate the condition by promoting clot dislodgement, making immediate notification of the healthcare provider the most appropriate nursing action in this situation.
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Falls are one of the leader environmental hazards reported in health facilities. One of the MOST common occurrences that precipitate a patient fall is
- A. experiencing stress, anxiety, and fatigue
- B. leaving the side rails down
- C. reaching item at the bedside
- D. performing activities of daily living
Correct Answer: B
Rationale: Leaving the side rails down is one of the most common occurrences that can lead to a patient fall. Side rails are important safety measures designed to prevent patients from falling out of bed. When the side rails are left down, the patient is at a higher risk of accidentally rolling out of bed and falling. It is crucial for healthcare providers to always ensure that the side rails are up and secure to help prevent patient falls.
systematic meta- analysis of the literature?
- A. An electronic database and doctoral dissertations
- B. An electronic database
- C. Doctoral dissertations
- D. The Cochrane Statistical Methods
Correct Answer: B
Rationale: Systematic meta-analysis of the literature typically involves synthesizing research findings from multiple studies on a particular topic. The most common way to gather relevant studies for a meta-analysis is by searching through electronic databases. These databases contain a wide range of peer-reviewed literature such as research articles, reviews, and conference papers. Using electronic databases ensures a comprehensive and systematic approach to finding all relevant studies needed for a meta-analysis. While doctoral dissertations and statistical methods such as those offered by Cochrane can also be valuable sources of information, an electronic database is the primary tool used for conducting a systematic meta-analysis of the literature.
Which of the following conditions is characterized by the formation of calcium oxalate or calcium phosphate stones within the renal collecting system?
- A. Ureteropelvic junction (UPJ) obstruction
- B. Ureterovesical junction (UVJ) obstruction
- C. Renal colic
- D. Nephrolithiasis
Correct Answer: D
Rationale: Nephrolithiasis refers to the formation of stones within the kidney or urinary tract. The most common types of kidney stones are either composed of calcium oxalate or calcium phosphate. When these stones form within the renal collecting system, they can lead to symptoms such as flank pain, hematuria, and urinary obstruction. Ureteropelvic junction (UPJ) obstruction and ureterovesical junction (UVJ) obstruction are specific types of blockages within the urinary system that can be caused by kidney stones but are not characteristic of the stone formation itself. Renal colic is the term used to describe the severe pain associated with the passage of a kidney stone through the ureter.
Which assessment finding would lead the nurse to suspect a postpartum hemorrhage? Blood loss of _____.
- A. less than 300 ml/24 hours
- B. more than 400 ml/24 hours
- C. less than 200 ml/2 hours
- D. more than 500 m2/24 hours
Correct Answer: D
Rationale: Postpartum hemorrhage is defined as a blood loss of more than 500 ml within the first 24 hours after vaginal delivery or more than 1000 ml following a cesarean delivery. Excessive bleeding can lead to hypovolemic shock and can be life-threatening if not promptly addressed. Therefore, a blood loss of more than 500 ml/24 hours would lead the nurse to suspect a postpartum hemorrhage and prompt further assessment and intervention.
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.