A woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures. What intervention should the nurse prioritize?

Correct Answer: A

Rationale: When a woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures, the nurse should prioritize providing continuous labor support. Continuous labor support, also known as a doula or labor companion, has been shown to be effective in reducing the perception of pain and improving labor outcomes. The presence of a supportive person can provide physical, emotional, and informational support, helping the woman cope with the pain and navigate through the labor process. This intervention can enhance the woman's overall experience of labor and improve maternal and neonatal outcomes without the need for pharmacological interventions. Administering opioids, performing epidural analgesia, or initiating nitrous oxide inhalation are pharmacological pain relief measures and may not align with the woman's preference for non-pharmacological options.

Correct Answer: B

Rationale: The nurse's best response to a patient expressing fear of the unknown regarding an upcoming surgical procedure is to provide the patient with accurate information about the surgical procedure and what to expect. This approach empowers the patient with knowledge and helps alleviate anxiety by demystifying the unknown. By educating the patient about the procedure, potential risks, and postoperative care, the nurse can help the patient feel more prepared and in control of the situation. It is crucial for healthcare providers to address patient fears with compassion, understanding, and information to support the patient through the surgical process.

Correct Answer: A

Rationale: The presentation of sudden-onset, painless vision loss in the right eye with a cherry-red spot at the macula and attenuated retinal vessels is classic for central retinal artery occlusion (CRAO). In this condition, the blockage of the central retinal artery results in severe ischemia of the retina, leading to rapid and profound vision loss. The cherry-red spot at the macula is a result of preserved choroidal circulation contrasting with the pale, ischemic retina. Attenuated retinal vessels are also commonly observed due to decreased blood flow. Prompt evaluation and management are critical in CRAO to potentially restore some vision and prevent further ischemic damage to the retina.

Correct Answer: A

Rationale: The patient's presentation of episodic throbbing headache associated with nausea, vomiting, sensitivity to light and sound, and aura suggests a diagnosis of migraine headache. Migraines are a common neurological condition characterized by recurrent moderate to severe headaches that are often unilateral, pulsating, and aggravated by physical activity. The presence of premonitory symptoms (aura) before the headache is a key feature commonly seen in migraines. Additionally, nausea, vomiting, and sensitivity to light and sound are also common features associated with migraines.

Correct Answer: A

Rationale: The nurse should prioritize ensuring proper zeroing and calibration of the ICP monitoring system to ensure procedural accuracy and reliability of the measurements obtained. Proper zeroing involves setting the transducer at the level of the patient's external auditory meatus (ear), which serves as a reference point for accurate ICP readings. Calibration is necessary to establish accurate pressure measurements. Incorrect zeroing or calibration can lead to inaccurate ICP readings, which can impact clinical decision-making for patients with traumatic brain injury. Positioning the patient in a high-Fowler's position, administering prophylactic antibiotics, or placing the ICP monitor in the subarachnoid space via lumbar puncture are not directly related to ensuring the accuracy of the ICP monitoring procedure.

Correct Answer: A

Rationale: Nurse Nilda immediately responds to any cry from her pediatric patients to attend to her patients who cannot communicate verbally. Crying is one of the few ways infants and young children communicate their needs and discomforts. By responding promptly to their cries, Nurse Nilda can assess and address potential issues such as hunger, pain, discomfort, or other needs that the child may have. This enhances the quality of care provided and helps in comforting and soothing the child, ultimately promoting their well-being and building trust between the nurse and the patient.

Correct Answer: A

Rationale: The theory that categorizes professionals as Novice to experts is by Patricia Benner. Patricia Benner developed the Novice to Expert model, which describes how individuals progress through five levels of proficiency in a skill or field. The five levels are Novice, Advanced Beginner, Competent, Proficient, and Expert. Benner's model is widely used in nursing education and research to understand how nurses develop their clinical skills and expertise over time.

Correct Answer: C

Rationale: Cryptosporidium parvum is a protozoan parasite often found in contaminated water sources. This parasite is known to cause watery diarrhea, abdominal cramps, and nausea in infected individuals. The presence of oocysts in the stool sample is characteristic of Cryptosporidium infection. Other parasitic infections may present with similar symptoms, but in this case, the most likely culprit based on the exposure history and laboratory findings is Cryptosporidium parvum.

Correct Answer: D

Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.