Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. what would be the nurse's FIRST action?

Correct Answer: B

Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.

Correct Answer: C

Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.

Correct Answer: A

Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.

Correct Answer: A

Rationale: Total knee arthroplasty (TKA), also known as total knee replacement, is a surgical procedure commonly performed to alleviate symptoms and improve function in patients with advanced osteoarthritis of the knee that has not responded to conservative management. During TKA, the damaged cartilage and bone in the knee joint are removed and replaced with prosthetic components. This procedure aims to reduce pain, restore function, and improve the quality of life for individuals with severe osteoarthritis of the knee. High tibial osteotomy (HTO) is typically performed in younger patients with unicompartmental osteoarthritis, while knee arthroscopy and meniscectomy are more targeted towards specific knee conditions and may not provide significant relief in cases of advanced osteoarthritis.

Correct Answer: D

Rationale: The BEST rationale for the conduct of the program is to deliver safe and quality nursing care to patients on intravenous therapy (IV). This directly ties the purpose of the program to the real-world outcome it seeks to achieve - providing optimal care for patients requiring intravenous therapy. Ensuring safe practice in the hospital (Option A) is important but it is not specific to the focus of the IV therapy program. Improving nursing practice in general (Option B) is a noble goal but the program should have a specific and targeted objective. Providing knowledge and skills to all nursing staff in IV Therapy (Option C) is essential, but the primary aim should be centered on improving patient care outcomes. Therefore, delivering safe and quality nursing care to patients on IV therapy aligns most closely with the core purpose of the program and should be the primary rationale.

Correct Answer: D

Rationale: The clinical presentation of chest pain, dyspnea, and a friction rub heard on auscultation is suggestive of pericarditis. The diffuse ST-segment elevation seen on the electrocardiogram (ECG) is a classic finding in pericarditis, known as the "universal sign." In contrast, stable angina typically presents with chest pain on exertion that is relieved by rest or nitroglycerin, while unstable angina presents with chest pain at rest or with minimal exertion. Acute myocardial infarction would typically present with ST-segment elevation in specific leads correlating with the area of myocardial ischemia/infarction. However, in the context of diffuse ST-segment elevation and symptoms suggestive of inflammation (friction rub), the most likely diagnosis is pericarditis.

Correct Answer: B

Rationale: Molluscum contagiosum is a viral skin infection caused by the poxvirus. It typically presents as multiple dome-shaped, translucent papules with central umbilication on the face and trunk. The lesions are usually asymptomatic but can be itchy. Molluscum contagiosum is a common infection in children but can also occur in adults, especially those who are immunocompromised. The lesions can gradually increase in number over time. Basal cell carcinoma, sebaceous hyperplasia, and keratoacanthoma do not typically present with the characteristic features of molluscum contagiosum.

Correct Answer: A

Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.

Correct Answer: C

Rationale: The most effective intervention to prevent pressure ulcers in bedbound patients at risk, such as those with advanced dementia, is to use pressure-relieving support surfaces like specialized mattresses or cushions. These surfaces help distribute the pressure evenly, reducing the risk of pressure ulcer formation on bony prominences. Turning the patient every 2 hours (choice A) can also help relieve pressure, but it may not be sufficient to prevent pressure ulcers in high-risk individuals. Applying barrier creams or moisture barriers (choice B) can help protect the skin but may not address the underlying issue of pressure on vulnerable areas. Administering prophylactic antibiotics (choice D) is not recommended for preventing pressure ulcers as it does not address the root cause of the problem and can lead to antibiotic resistance. Therefore, the priority intervention should be to use pressure-relieving support surfaces to minimize the risk of pressure ulcers in