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?

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Question 1 of 9

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.

Question 2 of 9

A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: A

Rationale: The correct answer is A: Anterior uveitis. This condition presents with redness, pain, and photophobia due to inflammation of the uveal tract. Ciliary injection, corneal edema, and mid-dilated pupil with fixed reaction to light are classic signs of anterior uveitis. The other choices can be ruled out based on specific findings: B: Acute angle-closure glaucoma would present with a high intraocular pressure, not fixed dilated pupil. C: Endophthalmitis typically presents with severe pain, hypopyon, and vitreous inflammation. D: Corneal abrasion would not cause ciliary injection or fixed dilated pupil.

Question 3 of 9

You should check the patient for suspect disturbed thought processes related to depressed metabolism and altered cardiovascular and respiratory status. What is the rationale for orienting the patient to time, place, date, and events?

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.

Question 4 of 9

At which stage of Lewin ' s planned change indicates the nurse identifying, planning, and implementing appropriate strategies ensuring that driving forces exceed restraining forces?

Correct Answer: C

Rationale: The correct answer is C: unfreezing. Unfreezing is the initial stage in Lewin's planned change model where individuals become open to change by recognizing the need for it. During this stage, the nurse identifies the need for change, plans strategies to implement it, and works on overcoming resistance by ensuring that the driving forces (reasons for change) outweigh the restraining forces (barriers to change). Refreezing (A) is the final stage where the changes are reinforced and integrated into the organization. Movement (B) is the stage where actual change occurs, and in activism (D) is not a recognized stage in Lewin's model.

Question 5 of 9

When patient record reach the Medical Records, the assigned staff will _____.

Correct Answer: C

Rationale: The correct answer is C because checking the completeness of the charting by doctors and nurses ensures that all necessary information is accurately documented, facilitating proper patient care and treatment. This step helps identify any missing or incorrect information that may impact patient safety. A: Storing the charts in respective shelves is a routine task that does not involve verifying the accuracy or completeness of the information. B: Separating medico-legal charts is important but does not directly address the completeness of charting by doctors and nurses. D: Binding the charts immediately is not necessary before ensuring the completeness and accuracy of the information documented.

Question 6 of 9

A patient with a history of nephrolithiasis presents with sudden-onset severe colicky flank pain radiating to the groin. On physical examination, there is tenderness over the costovertebral angle and hematuria. What is the most likely diagnosis?

Correct Answer: C

Rationale: The correct answer is C: Renal colic due to ureteral calculus. The sudden-onset severe colicky flank pain radiating to the groin along with tenderness over the costovertebral angle and hematuria are classic symptoms of kidney stones (ureteral calculus). The pain results from the obstruction of urine flow by the stone, leading to increased pressure and spasm in the ureter. Acute pyelonephritis (choice A) presents with fever, chills, and systemic symptoms. Renal artery embolism (choice B) typically presents with acute onset severe flank pain but is associated with risk factors like atrial fibrillation. Renal infarction (choice D) presents with sudden-onset severe flank pain but is less likely than ureteral calculus in a patient with a history of nephrolithiasis.

Question 7 of 9

The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?

Correct Answer: C

Rationale: The correct answer is C: Umbilicus. The nurse begins assessing the uterine fundus at the level of the umbilicus as it is a standard reference point for postpartum fundal height measurement. This location allows for consistency and accuracy in tracking the descent of the uterus back into the pelvic cavity. Starting at the umbilicus also helps in monitoring the involution process and prevents potential errors in fundal height assessment. Symphysis pubis (A) is too low and not typically used as a reference point for uterine fundal assessment. Midline (B) is vague and does not provide a specific anatomical landmark. Sides of the abdomen (D) do not give a standardized starting point for measuring the uterine fundus, leading to potential variability in assessment.

Question 8 of 9

The physician prescribes decongestant intranasal spray. The nurse instructs the client on the proper use of the spray. Which of the following procedures is the CORRECT method?

Correct Answer: D

Rationale: The correct answer is D: Tilt the head slightly forward and angle the bottle toward the side of the nostril. This method allows for proper administration of the spray into the nasal passage, ensuring effective delivery of the medication. Tilted head helps direct the spray towards the nasal cavity without causing discomfort or leakage. It also helps prevent the medication from dripping down the back of the throat. Choices A, B, and C are incorrect: A: Finishing instillation in one nostril before moving to the other can lead to uneven distribution of medication and reduced effectiveness. B: Inhaling quickly may cause irritation and discomfort to the mucous membranes due to the forceful intake of the spray. C: Blowing the nose after spraying can expel the medication before it has a chance to be absorbed, decreasing its efficacy.

Question 9 of 9

Nurse Merry 's application to Canada has finally been approved and she was advised to depart in three months But, she is also enrolled in the graduate school and ambivalent to go because of this engagement plus the fact that her mother has just been discharged from the hospital. Which of the following actions is BEST?

Correct Answer: C

Rationale: The correct answer is C. Nurse Merry should tell the recruiter to give her more time to settle her personal affairs before departing to Canada. This is the best action because it shows responsibility and consideration for her current commitments and family situation. By requesting more time, she can prioritize her mother's recovery and complete her graduate studies, demonstrating good decision-making skills and care for her loved ones. Option A is incorrect because it dismisses the importance of family and personal obligations. Option B is incorrect as it shows a lack of planning and responsibility. Option D is incorrect as it suggests running away from problems instead of addressing them responsibly.

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