During the postpartum assessment, a new mother reports experiencing mild cramping and uterine contractions while breastfeeding. What physiological process is responsible for these symptoms?

Correct Answer: B

Rationale: Oxytocin release is responsible for the mild cramping and uterine contractions experienced by the new mother while breastfeeding. When a baby suckles at the breast, it stimulates nerve endings that signal the release of oxytocin from the posterior pituitary gland. Oxytocin is a hormone that plays a crucial role in stimulating the contraction of the uterine muscles, helping the uterus to contract back to its pre-pregnancy size. This process, known as uterine involution, is essential for postpartum recovery and preventing excessive bleeding. Therefore, the new mother's experience of mild cramping and uterine contractions while breastfeeding is a normal physiological response mediated by the release of oxytocin.

Correct Answer: D

Rationale: Sudden chest pain, dyspnea, and tachycardia in a postpartum client can be indicative of serious conditions such as pulmonary embolism or myocardial infarction. These conditions are emergencies that require immediate medical attention. Notifying the healthcare provider immediately is the priority to ensure prompt evaluation and intervention to address the potential life-threatening situation. While other nursing interventions such as elevating the head of the bed, providing supplemental oxygen therapy, and administering analgesics may be necessary, they should be done after notifying the healthcare provider to ensure appropriate management of the underlying cause.

Correct Answer: B

Rationale: The primary objective of a birth plan is to provide a pregnant woman the opportunity to outline her wishes and preferences regarding her labor, delivery, and postpartum care. It allows the mother-to-be to communicate her desires to the healthcare team in advance, ensuring that her preferences are considered and respected during the birthing process. A birth plan typically covers various aspects such as pain management options, who she wants present during labor, interventions she may want to avoid, plans for after birth care, and any other specific requests she may have. Ultimately, a birth plan aims to empower the woman to have a more personalized and satisfying birth experience by actively involving her in the decision-making process.

Correct Answer: C

Rationale: The presentation described in the question (sensation of fullness and pressure in the left ear, hearing loss, occasional tinnitus, retracted tympanic membrane with decreased mobility on pneumatic otoscopy) is suggestive of serous otitis media, also known as otitis media with effusion. Serous otitis media occurs when fluid accumulates in the middle ear without signs of infection. This buildup of fluid in the middle ear space can cause the tympanic membrane to retract and reduce its mobility on pneumatic otoscopy.

Correct Answer: C

Rationale: Conducting a staff meeting is the best strategy for Nurse Nena to give feedback on patients' evaluation of health services. This option allows for direct communication and interaction with the team, ensuring that feedback is effectively conveyed, discussed, and understood by all members. Staff meetings provide a platform for open dialogue, clarification of any concerns, and collaborative problem-solving. It also promotes team cohesion and shared accountability in improving health services based on patients' feedback. This approach encourages active participation and engagement from all team members, fostering a more effective and comprehensive response to the evaluations received.

Correct Answer: C

Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.

Correct Answer: B

Rationale: Identifying the patient's stage of change is crucial when someone expresses a desire to be "detoxified" from a substance like marijuana. The Transtheoretical Model (Stages of Change) outlines different stages individuals go through when making behavior changes. By identifying which stage the patient is in (precontemplation, contemplation, preparation, action, maintenance, or relapse), the nurse can tailor interventions and support accordingly. This approach helps ensure that interventions are effective and appropriate for the individual's readiness for change. It is important to meet the patient where they are in their journey towards detoxification and offer support and guidance accordingly.

Correct Answer: A

Rationale: In prioritizing nursing diagnoses, the nurse should consider issues that pose the greatest risk to the patient's immediate well-being. A fluid volume deficit can lead to dehydration and potentially life-threatening complications, making it a priority to address. It is crucial to restore fluid balance to maintain normal body functions and prevent further deterioration of the patient's condition. Ensuring adequate hydration is essential for the patient's overall health and recovery. The other options, such as risk for pain, coping, and body image disturbances, while important, are not as urgent as addressing a fluid volume deficit.

Correct Answer: A

Rationale: The clinical presentation of fever, chills, headache, and myalgia following a trip to sub-Saharan Africa is highly suggestive of malaria, which is caused by the Plasmodium species. Specifically, the presence of intraerythrocytic ring forms and trophozoites on blood smear examination points towards Plasmodium falciparum as the most likely causative agent.