During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus?

Correct Answer: D

Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.

Correct Answer: B

Rationale: Breast tenderness is a hallmark symptom of premenstrual syndrome (PMS), which occurs in the days leading up to menstruation. This symptom is often associated with hormonal fluctuations during the menstrual cycle. Women may experience increased sensitivity and soreness in their breasts, making them feel tender or swollen. It is a common symptom of PMS and can vary in severity from one individual to another. Pelvic pain, postmenopausal bleeding, and dyspareunia are not typically considered hallmark symptoms of PMS.

Correct Answer: B

Rationale: First-voided morning urine is the best urine sample to be used for an accurate result of a pregnancy test done at home because it is more concentrated compared to urine samples collected at other times of the day. Overnight, the hCG hormone (human chorionic gonadotropin) builds up in a woman's body, making the early morning urine more likely to contain higher levels of hCG if a woman is pregnant. The concentrated nature of first-morning urine reduces the chances of false-negative results since it provides a higher concentration of the hormone that the test is designed to detect. Therefore, using first-morning urine increases the sensitivity of the pregnancy test and improves the accuracy of the results.

Correct Answer: A

Rationale: Zenker's diverticulum is a condition in which there is a pouch or sac that forms at the posterior pharyngeal wall above the upper esophageal sphincter. It can present with symptoms such as sensation of a foreign body stuck in the throat, difficulty swallowing (dysphagia), and odynophagia (painful swallowing). Flexible laryngoscopy can reveal a submucosal mass arising from the posterior pharyngeal wall, which is characteristic of Zenker's diverticulum.

Correct Answer: C

Rationale: The most effective strategy in preventing more incidence of dengue infection is to target the breeding places of the Aedes mosquitoes, which are the vectors responsible for transmitting the dengue virus. By eliminating stagnant water sources where these mosquitoes breed, such as uncovered containers, flower pots, and discarded tires, the mosquito population can be significantly reduced. This, in turn, helps to lower the risk of dengue transmission to humans. While healthy nutritious food, burning of leaves and garbage, and adequate rest and sleep are important for overall health and immune function, they do not directly address the primary cause of dengue transmission, which is the Aedes mosquito population.

Correct Answer: B

Rationale: Benign prostatic hyperplasia (BPH) is a condition characterized by an abnormal enlargement of the prostate gland, which is non-cancerous. This enlargement can lead to lower urinary tract symptoms such as urinary hesitancy (difficulty starting the urine stream), weak urinary stream, incomplete bladder emptying, frequent urination, urgency, and nocturia. BPH is a common condition in aging men and is not usually associated with prostate cancer. Other conditions like prostate cancer, prostatitis, and prostate adenoma may present with similar symptoms, but BPH is specifically characterized by the non-cancerous enlargement of the prostate gland. Treatment for BPH may include medications to improve symptoms or surgical procedures to reduce the size of the prostate gland.

Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Correct Answer: C

Rationale: Assessing the mental status of the patient is the PRIORITY nursing action to determine the patient's ability to concentrate and focus. This assessment includes evaluating the patient's level of alertness, orientation, memory, thought processes, and mood. By observing the patient's mental status, the nurse can gain valuable information about the patient's cognitive function, attention span, and ability to concentrate. This assessment will help guide further interventions and care planning for the patient. Asking for academic performance or conducting paper and pencil tests may be useful tools to assess concentration and focus, but they should come after a comprehensive evaluation of the patient's mental status. Referring the patient to a psychiatrist may be necessary based on the assessment findings, but it should not be the first step in determining the patient's ability to concentrate and focus.

Correct Answer: C

Rationale: The barrier to goal setting between the nurse and the family in this scenario is the failure of the family to perceive the existence of the problem. Goal setting in healthcare generally requires mutual agreement and understanding between the healthcare provider (nurse) and the patient/family. If the family does not perceive that there is an existing problem that needs to be addressed, there will likely be resistance or lack of motivation to set goals and work towards resolving the issue. This barrier can hinder effective communication, collaboration, and ultimately, the successful achievement of healthcare goals. It is important for the nurse to address this barrier through education, communication, and building trust to ensure that all parties are on the same page and actively participate in goal setting and care planning.