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: B

Rationale: The first step in the qualitative research process is typically conducting a review of existing literature on the topic of interest. This involves exploring existing research studies, theories, and findings related to the area being studied. By reviewing the literature, researchers can gain a better understanding of the current knowledge and identify gaps in the existing research that their study can address. This step helps researchers define the research question, refine the study design, and establish a strong theoretical framework for the study.

Correct Answer: A

Rationale: Bulimia nervosa is an eating disorder characterized by binge eating followed by compensatory behaviors such as self-induced vomiting, fasting, or excessive exercise. The repeated purging in bulimia can lead to electrolyte imbalances, such as hypokalemia (low potassium levels). Hypokalemia is a serious condition that can affect the function of the heart's electrical system, potentially leading to the development of cardiac arrhythmias (irregular heartbeats) and even cardiac arrest, which can result in death. Therefore, in a bulimic patient like Sherry, the risk of death is most likely due to the combination of hypokalemia and its complications, such as cardiac arrhythmias and arrest.

Correct Answer: A

Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.

Correct Answer: C

Rationale: A dental abscess is a condition characterized by inflammation and infection of the soft tissues surrounding the apex of a tooth root. This infection can result from untreated dental decay, trauma to the tooth, or periodontal disease. The abscess can cause pain, swelling, redness, and even pus formation. Treatment typically involves draining the abscess, removing the source of infection, and possibly prescribing antibiotics to address the infection. If left untreated, a dental abscess can lead to serious complications and spread to other parts of the body.

Correct Answer: B

Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.

Correct Answer: A

Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.

Correct Answer: A

Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.

Correct Answer: D

Rationale: For a diagnostic pelvic ultrasound, one important preparation is to have the patient void or empty their bladder before the procedure. This allows for better visualization of the pelvic organs and structures during the ultrasound scan. A full bladder can obstruct the view and make it difficult to obtain accurate images. Therefore, it is essential for the patient to follow instructions to empty their bladder before the pelvic ultrasound to ensure the best results.