Correct Answer: A

Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: D

Rationale: A hard mass and a reddened area on one breast are key clinical signs that confirm the diagnosis of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, and swelling of the breast. The presence of a hard mass along with the other symptoms suggests inflammation and infection within the breast tissue. In contrast, the other findings such as enlarged glands in the axilla, normal temperature, and engorged breasts are not specific findings for mastitis and may be present in other conditions. Therefore, the presence of a hard mass and reddened area on one breast is the additional finding that strongly confirms the diagnosis of mastitis in this case.

Correct Answer: B

Rationale: The signs reported by the patient, such as feeling nauseated, restless, sweating excessively, fatigue, and increased hunger, are indicative of hypoglycemia, which is characterized by low blood sugar levels. In individuals with hypoglycemia, these symptoms can occur when the blood glucose levels drop too low, leading to disturbances in the body's energy supply. This is common in individuals who may have experienced episodes of low blood sugar, especially if they have a history of diabetes or are taking medications that lower blood sugar levels. Diabetic nephropathy, hyperglycemia, and diabetic retinopathy are conditions associated with high blood sugar levels and are not consistent with the symptoms described by the patient.

Correct Answer: C

Rationale: Even though Ms. C's self-esteem and weight have improved, her continued negative self-talk and use of derogatory terms like "fatty" indicate a distorted perception of her body image. This distortion needs to be addressed and corrected for her overall long-term psychological well-being. By focusing on addressing the disturbed body image, the nursing team can help Ms. C develop a more positive self-perception and maintain the progress she has made towards recovery from anorexia nervosa. It is important to prioritize interventions that promote a healthier and more realistic body image in order to support her ongoing recovery journey.