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.

Correct Answer: B

Rationale: Administering ice packs to the perineum is the priority nursing intervention to provide relief for perineal pain and discomfort in a postpartum client. Ice packs help to reduce swelling and inflammation in the perineal area, which can help alleviate pain. It is a safe and effective method to provide immediate relief and promote comfort for the client. Other interventions such as encouraging ambulation, administering analgesics, and recommending warm sitz baths can also be beneficial, but in the initial management of perineal pain, ice packs are the most appropriate choice.

Correct Answer: B

Rationale: In this scenario, the firm and midline fundus at three hours postpartum indicates that the uterus is contracting well. The presence of a small constant trickle of blood on perineal inspection suggests ongoing bleeding. This combination of findings is concerning for retained placenta, where a portion of the placenta remains attached to the uterine wall and prevents proper contraction and closure of the blood vessels at the placental site. Retained placenta can lead to postpartum hemorrhage and requires prompt evaluation and intervention to prevent complications. Nurse Kayla should escalate this finding to the healthcare provider for further assessment and management.

Correct Answer: D

Rationale: The most appropriate diagnostic examination to confirm the incidence of hypertension among residents is blood pressure (BP) monitoring. Hypertension is defined by elevated blood pressure readings consistently measured over time. Monitoring of blood pressure is essential for diagnosing hypertension and determining the severity of the condition. Chest x-ray, ultrasound, and electrocardiogram are not specific tests for diagnosing hypertension. While these tests may be useful in assessing potential complications or causes of hypertension, they do not directly confirm the presence of high blood pressure. Regular BP monitoring with the use of a sphygmomanometer or automated blood pressure device is crucial in diagnosing and managing hypertension.

Correct Answer: C

Rationale: When a pregnant woman is diagnosed with preeclampsia, the focus of health care shifts to the individual woman herself. Preeclampsia is a serious condition that affects the health of the pregnant woman and her unborn child. The healthcare team will prioritize the care and treatment of the woman to ensure her well-being and safety. In this scenario, the emphasis is on providing personalized and targeted care to address the needs of the individual patient, rather than a broader focus on population groups, communities, or families.