A woman in active labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing action?

Correct Answer: B

Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.

Correct Answer: C

Rationale: Cryptosporidium parvum is a protozoan parasite that commonly causes waterborne illness characterized by watery diarrhea, abdominal cramps, and nausea. This parasite is often transmitted through contaminated water sources such as streams or lakes. Laboratory tests identifying oocysts in the stool sample are indicative of Cryptosporidium infection. Giardia lamblia can also cause similar symptoms, but the presence of oocysts points more towards Cryptosporidium in this case. Entamoeba histolytica causes amoebic dysentery with bloody diarrhea and is usually associated with fecal-oral transmission through contaminated food or water. Cyclospora cayetanensis typically causes prolonged watery diarrhea and is associated with the ingestion of contaminated food or water.

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).

Correct Answer: C

Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.

Correct Answer: A

Rationale: Two of the 8 Millennium Development Goals that are very specific to Maternal and Child Health (MCH) are "Reduce child mortality" and "Improve maternal health." These goals focus directly on the well-being of mothers and children, aiming to decrease child mortality rates and enhance the health of pregnant women.

Correct Answer: D

Rationale: Postpartum hemorrhage (PPH) is a significant complication after childbirth. The risk factors for PPH that are typically included in the list are uterine atony, overdistended uterus (e.g., multiple gestation or polyhydramnios), and ruptured uterus. Retroversion of the uterus is not a known risk factor for PPH. Retroversion refers to the position of the uterus, where it is tilted back towards the rectum. While retroverted uterus can sometimes lead to other issues or complications during pregnancy, it is not directly associated with an increased risk of postpartum hemorrhage.

Correct Answer: A

Rationale: The first responsibility of a nurse when a patient falls is to assess the patient's injury. Assessing the patient's injury immediately allows the nurse to determine the severity of the fall and provide appropriate care and interventions. It is important to assess for any signs of injury, such as pain, swelling, bruising, or altered mobility, and to address any immediate medical needs. Once the patient's injury has been assessed, the nurse can then proceed to report the incident to the head nurse, write an incident report, and notify the physician if necessary.

Correct Answer: A

Rationale: A retrospective audit involves reviewing past cases or data to evaluate processes, outcomes, or compliance with standards. In this scenario, the nursing team plans to audit post-op patients who developed pressure sores over the past year at the Orthopedic unit. By looking at historical data from the past year, the audit is considered retrospective as it assesses what has occurred over a specified period. This type of audit helps identify trends, patterns, and areas for improvement based on past events.

Correct Answer: D

Rationale: Record keeping involves several key steps such as structuring, securing, and storing information. However, easy disposal is not a step in record keeping. In fact, it is important to carefully consider the disposal of records in a secure and responsible manner to protect sensitive information and comply with relevant regulations. Proper disposal methods should be followed to ensure that records are not accessible to unauthorized individuals and that any sensitive information is properly destroyed to prevent misuse or breaches of privacy. Therefore, easy disposal is not a recommended practice in effective record keeping.