A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?

Correct Answer: D

Rationale: In this scenario, the correct answer is option D (N/A) because during a contraction assessment in labor, the focus should be on uterine activity, fetal heart rate, maternal vital signs, and pain level. None of the options provided directly address these key parameters. Option A (heart rate increase from 76 bpm to 90 bpm) could be a normal physiological response to labor and may not necessarily be a cause for concern during a contraction unless there are other accompanying signs of distress. Option B (blood pressure rise from 110/60 mm Hg to 120/74) could also be a normal response to labor due to increased pain and stress. It is important to assess trends rather than isolated readings in such cases. Option C (white blood cell count of 12,000 cells/mm3) is unrelated to the immediate assessment of a woman in labor and does not indicate a cause for concern during a contraction. This question serves as a reminder of the importance of focusing on pertinent assessment findings during labor and delivery, emphasizing the need for nurses to prioritize and interpret data accurately in order to provide safe and effective care to women and their newborns.

Correct Answer: A

Rationale: The correct answer is A) The man will ejaculate by masturbation into a specially designed condom. In this scenario, the conflict with the Roman Catholic couple's religious beliefs stems from the act of masturbation, which is considered sinful according to Catholic teachings. Masturbation is seen as contrary to the procreative purpose of sexual intercourse within marriage. Option B) The woman may become pregnant with donor sperm may not necessarily conflict with their beliefs as long as the sperm is from the woman's husband or within the marriage. Option C) Fertilization is occurring in the artificial environment of the laboratory does not directly contradict Catholic beliefs as the issue lies more with the method of sperm collection. Option D) More embryos will be created than will be used to inseminate the woman might raise ethical concerns about unused embryos but does not directly conflict with Catholic teachings regarding the act of masturbation. Educationally, understanding the religious and ethical considerations that may impact healthcare decisions is crucial for providing culturally sensitive care. Nurses must be aware of these nuances to support patients in making informed choices that align with their beliefs and values.

Correct Answer: B

Rationale: In this scenario, option B) Nitroglycerin ingestion for angina pectoris is the correct answer as a contraindication for Viagra use in a man being treated for erectile dysfunction. Nitroglycerin is a vasodilator that works by relaxing blood vessels, leading to a drop in blood pressure. When combined with Viagra, another vasodilator, there is a significant risk of severe hypotension, which can be life-threatening. Option A) Preexisting diagnosis of herpes simplex 2 is incorrect because it is not a contraindication for Viagra use. Herpes simplex 2 is a viral infection and does not directly interact with Viagra in a way that would make it unsafe for use in this context. Option C) Retinal damage from type I diabetes mellitus is incorrect because although Viagra can rarely cause visual disturbances, retinal damage from diabetes is not a direct contraindication for its use. Option D) Postsurgical care for resection of the prostate is incorrect because Viagra is commonly used to treat erectile dysfunction following prostate surgery, and there is no direct contraindication for its use in this scenario. In an educational context, understanding contraindications of medications is crucial for safe and effective patient care. Healthcare providers need to be aware of potential drug interactions and contraindications to prevent adverse effects and ensure the best outcomes for their patients.

Correct Answer: D

Rationale: The correct answer is option D: "You should experience the same sensations you feel when your doctor does your Pap test." Rationale: Option D is correct because it provides accurate information about what the client can expect during the postcoital test. The sensation during a Pap test involves a speculum examination of the cervix, which is similar to the examination performed during a postcoital test. This statement helps prepare the client for the procedure and reduces anxiety. Option A is incorrect because the timing of a postcoital test is not related to the menstrual cycle but is usually scheduled within a specific timeframe after intercourse. Option B is incorrect as it describes a hysterosalpingogram (HSG) where dye is used to visualize the fallopian tubes and uterus, not a postcoital test. Option C is incorrect as refraining from intercourse for four days prior to the test is not necessary for a postcoital test, as the purpose is to evaluate cervical mucus changes after intercourse. Educational Context: Educating clients about fertility testing procedures is crucial for informed decision-making and reducing anxiety. Providing accurate information about what to expect during tests helps clients feel more comfortable and prepared. Understanding the rationale behind each answer enhances clinical knowledge and promotes effective patient education in infertility care.

Correct Answer: D

Rationale: In the context of a client hospitalized with severe ovarian hyperstimulation syndrome and experiencing fluid volume excess due to third spacing, the highest priority nursing goal is ensuring the client's lung fields remain clear throughout hospitalization (option D). This is crucial because fluid volume excess can lead to pulmonary complications such as pulmonary edema and impaired gas exchange. Maintaining clear lung fields is essential for adequate oxygenation and preventing respiratory distress in this critical condition. Option A, focusing on the client's weight, is not the highest priority as it does not directly address the immediate risk of respiratory compromise from fluid volume excess. Option B, regarding skin breakdown, is important but secondary to ensuring respiratory function. Option C, related to electrolyte levels, is also important but does not address the urgent need to maintain clear lung fields in the face of fluid excess. In an educational context, understanding prioritization of nursing goals is crucial in providing effective and safe care to patients. This question highlights the need for nurses to identify the most critical issue that requires immediate attention to prevent complications and prioritize interventions accordingly. It emphasizes the importance of clinical judgment and critical thinking in delivering quality patient care.