A woman in active labor is experiencing umbilical cord prolapse. What is the priority nursing action?

Correct Answer: B

Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.

Correct Answer: C

Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.

Correct Answer: A

Rationale: Long-term corticosteroid use in patients with rheumatoid arthritis can lead to osteoporosis, which is a common complication. Osteoporosis causes weakening of the bones, increasing the risk of fractures, particularly in weight-bearing bones such as the hip, spine, and wrist. Osteoporotic fractures are a significant concern in patients on long-term corticosteroid therapy, highlighting the importance of monitoring bone health and considering preventive measures such as calcium, Vitamin D supplementation, and regular bone density testing. While osteonecrosis of the femoral head and avascular necrosis of the talus can also occur as complications of corticosteroid use, osteoporotic fractures are more commonly associated with this type of therapy in patients with rheumatoid arthritis. Septic arthritis, on the other hand, is not directly related to corticosteroid use but can occur due to other factors such as joint infections.

Correct Answer: B

Rationale: In a patient with acute respiratory failure and hypercapnia due to a COPD exacerbation, the most appropriate intervention is the initiation of non-invasive positive pressure ventilation (NIPPV). NIPPV helps improve ventilation and oxygenation by providing mechanical support to the patient's breathing without the need for endotracheal intubation. It can reduce the work of breathing, decrease carbon dioxide retention, and improve respiratory muscle function. This intervention is particularly beneficial for COPD exacerbations as it can help alleviate hypercapnia and hypoxemia, leading to improved outcomes and potentially reducing the need for invasive ventilation methods. Therefore, NIPPV is the recommended management strategy in this scenario.

Correct Answer: B

Rationale: Meconium-stained amniotic fluid indicates that the fetus may have passed stool in utero, which can lead to potential respiratory problems once born due to meconium aspiration. The priority action for the nurse in this situation is to prepare for immediate delivery to expedite the removal of the fetus from the contaminated environment and provide necessary interventions such as suctioning of the airway to prevent aspiration of meconium. Prompt delivery is crucial to minimize the risk of complications related to meconium aspiration syndrome. Administering oxygen, inserting a urinary catheter, and notifying the neonatal resuscitation team can be important subsequent actions, but the immediate focus should be on delivering the baby.

Correct Answer: B

Rationale: Pain is best described as a subjective unpleasant experience because it is unique to each individual and is influenced by a variety of factors including emotional, psychological, and cultural elements. Pain cannot be objectively measured or quantified, and therefore it is considered a subjective experience that is reported by the person experiencing it. This is why pain is often assessed using self-report scales and tools to capture the individual's perception of their pain intensity and quality.

Correct Answer: A

Rationale: The clinical findings of inspiratory crackles (also known as rales) and dullness to percussion are most consistent with a diagnosis of pneumonia. Inspiratory crackles are abnormal lung sounds heard on auscultation and are typically due to the presence of fluid or mucus in the alveoli. Dullness to percussion can indicate consolidation of lung tissue, which is a common finding in pneumonia where the alveolar spaces are filled with inflammatory exudate. These findings suggest localized lung pathology and are commonly observed in patients with pneumonia. Hemoptysis and pleuritic chest pain (Choice B) are more suggestive of pulmonary embolism or pleurisy. Clubbing of the fingers and cyanosis (Choice C) are signs of chronic hypoxemia and are not specific to pneumonia. Decreased breath sounds and tracheal deviation (Choice D) are more indicative of conditions such as a pneumoth

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.

Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.