A woman in active labor is receiving intravenous antibiotics for group B streptococcus (GBS) prophylaxis. What maternal assessment finding indicates a potential adverse reaction to the antibiotics?

Correct Answer: B

Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.

Correct Answer: A

Rationale: In the case of a displaced fracture of the distal radius and ulna, the preferred initial treatment is typically closed reduction and splinting. Closed reduction involves manually realigning the fractured bones without the need for surgery. Splinting is then utilized to immobilize the wrist and forearm to allow for proper healing of the fracture. This approach is often effective in realigning the bones and stabilizing the injury, allowing for adequate healing without the need for more invasive interventions like surgery. Following the initial management with closed reduction and splinting, the patient's progress will be monitored, and further interventions may be considered based on the specific characteristics of the fracture and the patient's response to treatment.

Correct Answer: C

Rationale: When documenting pitting edema in a patient's notes, it is important to include details such as the degree of edema (A), duration of indentation (B), and depth of edema (D) as these parameters are relevant in assessing the severity of the condition and monitoring changes over time. However, mentioning the degree of temperature (C) is not directly related to assessing pitting edema. Temperature is typically assessed as part of a general physical assessment for signs of infection or inflammation and is not specifically needed when documenting pitting edema.

Correct Answer: A

Rationale: ORNAP stands for Operating Room Nurses Association of the Philippines. As Merle has been assigned in the Operating Room for 3 years and is interested in actively joining a professional organization related to this field, ORNAP would be the most appropriate choice. ORNAP focuses on promoting excellence in perioperative nursing practice through education, research, and collaboration. By joining ORNAP, Merle can further enhance her knowledge and skills in the Operating Room setting, as well as network with other professionals in the same field.

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: C

Rationale: The appropriate and recommended site for insulin injection to help avoid hypoglycemia is the abdominal wall subcutaneously. This site offers a consistent and reliable rate of absorption of insulin into the bloodstream. By injecting insulin into the abdominal wall subcutaneously, it allows for better control of blood sugar levels and reduces the risk of hypoglycemia. Additionally, it is important to rotate injection sites within the chosen area to prevent the development of lipohypertrophy (thickened, rubbery areas under the skin), which can affect insulin absorption.

Correct Answer: C

Rationale: The most effective plan would be for the nurse to educate the entire family at the same time about the disease and medications to treat it (Option C). This approach ensures that each family member receives the same information and understanding about obsessive compulsive disorder (OCD) and its treatment. By educating the entire family simultaneously, it creates a supportive environment where everyone is on the same page and can provide understanding and assistance to the individual with OCD, in this case, Mrs. Juan. It also allows for open communication and collaboration within the family unit, leading to better management and support for Mrs. Juan in dealing with her illness.

Correct Answer: B

Rationale: Negligence refers to the failure to perform a duty of care that a reasonable person would have exercised in the same situation, resulting in harm or injury to another person. In this scenario, the nurse failed to perform an ordered irrigation of a feeding tube, which is a standard nursing duty. This failure to act according to the orders resulted in harm to the patient, indicating negligence on the part of the nurse. Malpractice is a specific type of negligence that occurs when a professional fails to provide the standard level of care, so in this case, it falls under the broader category of negligence. Harm to the patient is the consequence of the nurse's negligence, and failure to follow the nurse practice act may be a contributing factor to the negligence, but the primary issue is the failure to provide proper care - which is negligence.

Correct Answer: A

Rationale: Benign prostatic hyperplasia (BPH) can lead to urinary retention, which is a common complication associated with this condition. As the prostate gland enlarges, it can obstruct the flow of urine from the bladder through the urethra. This obstruction can result in difficulty starting to urinate, weak urine flow, frequent urination, incomplete bladder emptying, and eventually urinary retention. If left untreated, urinary retention can lead to serious complications such as urinary tract infections, bladder damage, kidney damage, and even kidney stones. Therefore, urinary retention is an important complication to be aware of in patients with BPH.