Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.

Correct Answer: A

Rationale: Urinary tract infections are strongly associated with the occurrence of preterm labor. It is important to screen for and address any urinary tract infections during pregnancy to reduce the risk of complications like preterm labor. Diagnostic procedures, such as obtaining a urine sample for testing, help healthcare providers identify and treat any infections promptly to promote a healthy pregnancy. Therefore, the nurse can explain to Patient Presley that the diagnostic procedure is necessary to detect and address any potential urinary tract infections that could impact her pregnancy.

Correct Answer: C

Rationale: Rapid capillary refill is a sign indicative of shock in a trauma patient. Shock is a life-threatening condition where the body's organs and tissues do not receive adequate blood flow and oxygen, leading to cellular damage and eventual organ failure. In a trauma patient, rapid capillary refill suggests poor perfusion, which is a common feature of shock. The capillary refill time is an important clinical assessment that measures the time it takes for color to return to the nail bed after pressure is applied. In cases of shock, the refill time is faster than normal, indicating a systemic circulatory disturbance. Other signs of shock may include tachycardia (increased heart rate), hypotension (not hypertension), and hypothermia (not hyperthermia).

Correct Answer: C

Rationale: The central theme of Sr. Callista Roy's theory is adaptation. Roy's Adaptation Model focuses on the individual's ability to adapt to internal and external stimuli in order to maintain health and well-being. The theory emphasizes the interconnectedness of the individual and their environment, highlighting the dynamic process of adaptation in response to stimuli. By focusing on adaptation, Roy's theory guides nursing practice in promoting holistic care that supports individuals in adapting to changes and achieving optimal health outcomes.

Correct Answer: D

Rationale: Prinzmetal's angina, also known as variant angina, is characterized by episodes of chest pain that occur at rest and are relieved by nitroglycerin. Patients with Prinzmetal's angina may also have transient ST-segment elevation on an electrocardiogram (ECG) during episodes of chest pain. This is due to coronary artery vasospasm, which causes temporary obstruction of blood flow to the heart muscle. Stable angina typically presents with chest pain on exertion that resolves with rest, while unstable angina and acute myocardial infarction present with chest pain that is not relieved with nitroglycerin and are associated with more severe coronary artery disease.