A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?

Correct Answer: A

Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.

Correct Answer: B

Rationale: The gallbladder is the structure responsible for storing and concentrating bile produced by the liver until it is needed for digestion. Bile is a digestive fluid that helps in the breakdown of fats during the digestive process. When food containing fats enters the small intestine, the gallbladder contracts and releases bile into the small intestine to aid in the digestion and absorption of fats. The gallbladder acts as a reservoir for bile, storing it until it is needed for digestion.

Correct Answer: D

Rationale: It is NOT recommended to use the same syringe and needle in administering two different vaccines. This is to prevent contamination or mixing of different vaccines, which could potentially affect their effectiveness or pose a risk to the individual receiving the vaccines. It is important to use separate syringes and needles for each vaccine to ensure proper administration and prevent any adverse reactions.

Correct Answer: A

Rationale: Beta-blockers are a class of medications commonly used to manage hypertension. One of the main mechanisms of action of beta-blockers is to reduce heart rate and contractility by blocking the beta-adrenergic receptors in the heart. As a result, one of the potential adverse effects of beta-blockers is bradycardia, which refers to a slower than normal heart rate. Therefore, the nurse should closely monitor the patient for signs and symptoms of bradycardia when starting or adjusting the dose of a beta-blocker. Symptoms of bradycardia may include dizziness, fainting, fatigue, or shortness of breath. If bradycardia is severe or symptomatic, it may require dose adjustments or discontinuation of the beta-blocker to prevent complications.

Correct Answer: C

Rationale: Ménière's disease is characterized by the triad of symptoms including progressive sensorineural hearing loss, tinnitus, and vertigo. The audiometric testing in Ménière's disease often shows a "carrot-shaped" configuration, which refers to low-frequency hearing loss initially and eventually spreading to involve higher frequencies. This distinctive pattern of hearing loss helps differentiate Ménière's disease from other causes like Presbycusis (age-related hearing loss) or Noise-induced hearing loss. Acoustic neuroma can present with unilateral sensorineural hearing loss but typically does not exhibit the specific "carrot-shaped" configuration seen in Ménière's disease.

Correct Answer: A

Rationale: When collecting evidence from a rape victim, it is important to handle the victim's clothing properly to preserve any potential evidence. The preferred method is to remove the clothing and place them in a paper bag. Paper bags are used in order to prevent the alteration or degradation of any DNA evidence that may be present on the clothing. Paper bags allow the clothing to breathe and prevent the growth of mold or other contaminants that can occur in plastic bags or trash bags. Additionally, paper bags help preserve trace evidence such as fibers or hairs that may be crucial in the investigation of the case. It is essential to handle and store the clothing correctly to maintain the integrity of the evidence for the investigation and potential prosecution.

Correct Answer: C

Rationale: In a conscious trauma patient with a suspected head injury, maintaining cervical spine immobilization is crucial. The presence of a head injury raises concerns for potential concomitant cervical spine injury. Therefore, it is vital to prevent any movement of the cervical spine to avoid exacerbating a potential spinal cord injury. Maintaining immobilization involves stabilizing the patient's head and neck in a neutral position until appropriate imaging studies can assess the extent of any spinal injury. This action helps prevent further harm and ensures the safety of the patient during assessment and management of their injuries.

Correct Answer: A

Rationale: Having a tracheostomy means that a patient has an artificial opening in their neck to help them breathe. Therefore, any issues related to breathing, such as blockages in the tracheostomy tube or difficulty in clearing secretions, can pose a major problem for a patient with a tracheostomy. It is crucial to monitor the patient's respiratory status closely and intervene promptly if any breathing difficulties arise to prevent potential respiratory distress or complications.

Correct Answer: A

Rationale: Nurses play a crucial role as collaborators in the diagnostic process of psychiatric patients. While nurses themselves do not diagnose psychiatric conditions, they work closely with other healthcare providers such as psychiatrists and psychologists in assessing and monitoring patients' mental health status. Nurses gather valuable information, observe patients' behaviors, and communicate effectively with the healthcare team to contribute to the overall diagnostic process. By actively participating in assessments and evaluations, nurses help ensure accurate diagnoses and appropriate treatment plans for psychiatric patients.