A woman in active labor is diagnosed with uterine rupture, resulting in fetal distress and maternal hemorrhage. What nursing intervention is essential in managing this obstetric emergency?

Correct Answer: C

Rationale: Uterine rupture is a severe obstetric complication that requires prompt and decisive management to prevent adverse outcomes for both the mother and the baby. In cases of uterine rupture leading to fetal distress and maternal hemorrhage, performing an emergency cesarean section is crucial. This intervention allows for rapid delivery of the baby, relieving the distress on the fetus and enabling immediate access to manage the maternal hemorrhage. By performing a timely cesarean section, healthcare providers can expedite the delivery process and effectively address both the fetal and maternal complications associated with uterine rupture. This intervention is essential in saving lives and reducing the risk of further complications in such a critical obstetric emergency.

Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.

Correct Answer: B

Rationale: Hodgkin's disease commonly affects young adults between the ages of 15 to 35 and older adults over the age of 50. It is not a disease that occurs most often in older adults. In fact, Hodgkin's disease has a bimodal distribution, meaning it peaks in young adults and again in older adults. It is important to consider the age distribution when suspecting Hodgkin's disease and not exclusively associate it with older adults.

Correct Answer: D

Rationale: The best course of action in this scenario is to place a warm wet washcloth over Claudia's eyes for at least three minutes. This will help soften and loosen the dried crust, making it easier to gently clean her eyes and open them. Applying eye drops or ointment may not be effective if the crust is blocking her eyes completely. By using a warm wet washcloth, you can improve the ability to clean her eyes effectively and without causing discomfort.

Correct Answer: B

Rationale: Pelvic inflammatory disease (PID) is the most likely cause of the symptoms described in the pregnant woman. PID is an infection of the female reproductive organs, typically caused by sexually transmitted bacteria like Chlamydia or Gonorrhea. The classic presentation includes lower abdominal pain, fever, vaginal discharge, cervical motion tenderness, and bilateral adnexal tenderness on examination. This condition can lead to serious complications if not promptly treated, including infertility, ectopic pregnancy, and chronic pelvic pain. Therefore, it is crucial to diagnose and manage PID promptly, especially in pregnant women, to prevent adverse outcomes.

Correct Answer: B

Rationale: The past medical history section typically includes information about a person's medical background before the current point in time. This would involve details such as prenatal history, birth history, childhood illnesses, surgeries, and medical conditions that have occurred in the past. "Current history" would be more appropriate for the present medical status and ongoing health issues, hence it does not belong in the past medical history section.

Correct Answer: A

Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.

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 primiparous patient who complains of unrelieved perineal pain on the first postpartum day, Nurse Kayla should assess for a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can cause significant pain and discomfort. It can be a result of trauma during delivery or due to a blood vessel rupture. This condition requires prompt assessment and intervention to prevent complications such as infection or excessive bleeding. Vaginal laceration would typically be identified during the delivery process and would have been repaired by the healthcare provider. History of drug abuse, while important to know for overall patient care, is not as relevant in this immediate postpartum pain assessment. Puerperal infection usually presents with other signs such as fever, foul-smelling discharge, and uterine tenderness, which are not mentioned in this scenario.