A woman in active labor is experiencing precipitous labor with rapid cervical dilation and descent of the fetal presenting part. What maternal complication should the nurse anticipate?

Correct Answer: A

Rationale: Precipitous labor is characterized by rapid cervical dilation and descent of the fetal presenting part, leading to a shortened labor duration of less than 3 hours. This rapid progression can increase the risk of maternal complications, such as postpartum hemorrhage. Postpartum hemorrhage is defined as excessive bleeding of more than 500 ml after vaginal delivery or more than 1000 ml after cesarean delivery. The rapid delivery in precipitous labor can result in inadequate uterine contractions after delivery, leading to poor uterine tone and potential postpartum hemorrhage due to uterine atony. Therefore, the nurse should anticipate postpartum hemorrhage as a potential maternal complication in a woman experiencing precipitous labor.

Correct Answer: C

Rationale: The correct answer is C: Cells die. In Alzheimer's disease, there is a progressive degeneration of brain cells, leading to cell death. This results in a loss of important brain functions such as memory, cognition, and eventually, bodily functions. The atrophy of the brain stem (choice A) is not a characteristic feature of Alzheimer's. Fluid buildup (choice B) is not a primary mechanism of the disease. Tissue swelling (choice D) is not typically associated with the progression of Alzheimer's; rather, there is a gradual loss of brain tissue due to cell death.

Correct Answer: B

Rationale: The correct answer is B: How the nurse will behave. Standards of nursing care refer to the expected behaviors and practices that nurses should adhere to in providing quality care to patients. This encompasses ethical principles, professional conduct, and best practices in nursing. It is essential for nurses to follow these standards to ensure patient safety and quality outcomes. Explanation: - A: What protects the nurse. This choice is incorrect because standards of nursing care primarily focus on patient care and outcomes, rather than protecting the nurse. - C: How much work is done. This choice is incorrect as it does not directly relate to the behaviors and practices expected of nurses in providing quality care. - D: Ask the local officials. This choice is unrelated to the concept of standards of nursing care and is not relevant to the question.

Correct Answer: C

Rationale: The correct answer is C: Primary prevention. In this scenario, the clinic focuses on preventing disease before it occurs through health education and immunization. Primary prevention aims to promote general health and prevent the onset of diseases. It targets the entire population to reduce the risk of disease occurrence. Incorrect Choices: A: Diagnosis and treatment - This choice involves identifying and treating existing health conditions, which is not the primary focus of a clinic designed for health education and immunization. B: Secondary prevention - This choice involves early detection and treatment of diseases to prevent complications, which is more focused on individuals who already have risk factors or symptoms, not on the general population. D: Tertiary prevention - This choice involves managing and treating complications of diseases to prevent further deterioration, which is not the primary goal of a clinic focused on health education and immunization.

Correct Answer: C

Rationale: In a postpartum client complaining of persistent, heavy vaginal bleeding, the most appropriate nursing action is to assess vital signs and uterine tone. This is important to determine if the bleeding is within normal limits or if there is a potential postpartum hemorrhage (PPH) occurring. Monitoring vital signs can help identify signs of shock, while assessing uterine tone can help determine if the uterus is contracting effectively to control bleeding. Prompt assessment and early detection of PPH are crucial for effective management and prevention of complications. Encouraging increased fluid intake, applying a cold compress, and administering pain medication may be appropriate interventions in some situations, but assessing vital signs and uterine tone take priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B because the nurse's role is to address the holistic needs of the patient, including financial concerns. Providing information about financial assistance programs and resources shows empathy and supports the patient in making informed decisions. Choice A is incorrect because dismissing the patient's concerns can lead to a breakdown in trust and communication. Choice C is incorrect as ignoring the patient's concerns is not addressing the patient's needs. Choice D is incorrect because financial concerns are valid and should be considered in decision-making.

Correct Answer: B

Rationale: The correct answer is B: Provides reality orientation to patient. Orienting the patient to time, place, date, and events helps them stay connected to reality and improves their awareness of their surroundings. This is crucial in assessing their cognitive functioning and ensuring they are grounded in the present moment. By providing reality orientation, healthcare providers can better understand the patient's current mental state and address any potential confusion or disorientation. This approach aids in establishing a therapeutic environment and enhances the patient's overall well-being. Choices A, C, and D do not capture the essence of reality orientation and its significance in maintaining the patient's mental clarity and connection to the present moment.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Asking the patient about their cultural background and preferences shows respect for their individuality and acknowledges the importance of cultural competence in providing person-centered care. 2. It allows the nurse to gain valuable insights into the patient's beliefs, values, and practices, enabling them to deliver culturally appropriate care. 3. By prioritizing this aspect, the nurse can establish rapport, build trust, and enhance communication with the patient, leading to better outcomes. 4. Choices A, C, and D are incorrect as they either involve assumptions, avoidance, or disregard for the patient's cultural background, which can lead to misunderstandings, discomfort, and ineffective care.

Correct Answer: A

Rationale: Correct Answer: A - sterile clamps Rationale: 1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space. 2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space. 3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection. 4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation. Summary of other choices: B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space. C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube. D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.