Correct Answer: B

Rationale: Nursing interventions should be aimed at addressing the mother's needs for psychological security. Hyper vigilance and excessive worry about her child's safety indicate a lack of security in her mind. By providing support, reassurance, and education, nurses can help the mother feel more secure in her role as a parent and reduce her feelings of anxiety and distress. Establishing trust and building a therapeutic relationship can also contribute to enhancing the mother's psychological security and well-being.

Correct Answer: B

Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.

Correct Answer: D

Rationale: In this scenario, the mother, who is 35 years old and illiterate but with on and off seizure, is the best candidate to sign the informed consent for a surgical procedure for the child. The mother is the primary caregiver and decision-maker for the child in most cases, and her relationship to the child is most crucial in this situation. Despite her illiteracy, she can still comprehend the importance of the procedure for her child's well-being. Additionally, accommodations can be made for an illiterate person to sign the consent form by using an "X" as a signature. It is important that the person signing the consent form has a clear understanding of the risks and benefits involved, as well as the ability to make decisions in the best interest of the child.

Correct Answer: B

Rationale: Nurses are bound by strict confidentiality and privacy regulations in their profession. If a nurse fails to keep a patient's personal information confidential and discloses it without authorization, they can be charged with invasion of privacy. Invasion of privacy is the wrongful intrusion into a person's private affairs without their consent, and it is a serious violation of ethical and legal standards in healthcare. Nurses must always prioritize patient confidentiality to maintain trust and uphold ethical standards in their practice.

Correct Answer: B

Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.