Nurse Nora observes that the Ellie's uterine contractions are irregular in frequency and short in duration. Ellie screams in pain during contractions. Which of the following actions is considered BEST for the nurse to perform?

Correct Answer: B

Rationale: Administering pain relief medication as ordered is the best action for the nurse to take in this situation where the patient is experiencing intense pain during irregular and short uterine contractions. Pain relief medications can help alleviate the discomfort and distress that Ellie is experiencing, providing her with much-needed relief and improving her overall comfort during labor. It is important for the nurse to follow the prescribed orders for pain relief medication to ensure safe and effective pain management for the patient.

Correct Answer: B

Rationale: Assisting the client to a seated position on the toilet should be implemented first. This position promotes relaxation of the pelvic floor muscles and can help facilitate urinary elimination. It is a non-invasive and least intrusive intervention compared to performing intermittent catheterization or administering diuretic medication. Encouraging the client to drink plenty of fluids is important for promoting overall urinary function, but in this case, the priority is to aid the client in attempting to void first.

Correct Answer: D

Rationale: Radical abdominal hysterectomy involves the removal of the uterus, ovaries, ligaments (including round ligaments and uterosacral ligaments), and fallopian tubes. This extensive procedure is typically done for cases of invasive gynecologic cancers, most commonly cervical or ovarian cancer. The goal of radical hysterectomy is to remove as much of the cancerous tissue as possible to improve the chances of successful treatment and reduce the risk of cancer recurrence.

Correct Answer: A

Rationale: Neutrophils are a type of white blood cell that play a crucial role in immune defense against pathogens, particularly in phagocytosis - the process by which they engulf and destroy invading microorganisms. In a severe fungal infection, impaired neutrophil function would most likely affect their ability to effectively perform phagocytosis, leading to a compromised immune response against the fungal pathogen. This would result in increased susceptibility to the infection and potentially severe outcomes for the patient. Antibody production, cytokine secretion, and mast cell degranulation are important components of the immune response, but neutrophils are primarily responsible for phagocytosis in the innate immune system.

Correct Answer: B

Rationale: The patient's presenting symptoms of chest pain worsened by inspiration and relieved by sitting forward, with associated DVT in the lower extremity, suggest a high likelihood of pulmonary embolism. Chest pain that worsens with inspiration due to pleuritic involvement is a classic symptom of pulmonary embolism. Additionally, the presence of DVT in the lower extremity represents a risk factor for the development of pulmonary embolism, as clots originating in the deep veins can travel to the pulmonary circulation to cause an obstruction. Patients with pulmonary embolism may also exhibit signs of right heart strain, such as tachycardia, tachypnea, and sometimes hemoptysis.

Correct Answer: A

Rationale: Providing education on techniques to improve latch and milk transfer should be prioritized to support successful breastfeeding in this situation. Newborns who are macrosomic (large for gestational age) may have difficulties latching due to their size and may require additional support to effectively breastfeed. By educating the postpartum client on proper latch techniques and milk transfer, the nurse can help optimize the breastfeeding experience for both the mother and baby. This intervention focuses on addressing the specific concerns related to the infant's size and aims to promote successful breastfeeding despite potential challenges. As such, recommending supplemental formula feedings, encouraging the client to avoid breastfeeding, or immediately referring to a lactation consultant may not directly address the immediate need for support in improving breastfeeding in this situation.

Correct Answer: C

Rationale: The health care team will try the oral route first for Ms. C for delivering nutrition and fluid because it is the most natural and least invasive method. If the patient is able to tolerate oral intake and has adequate oral intake, it is typically the preferred route. Only if she is unable to meet her nutritional needs orally or has difficulty swallowing, then alternative routes such as nasogastric tube, gastrostomy tube, or intravenous routes may be considered. It's important to promote oral intake whenever possible to maintain the patient's quality of life and prevent complications associated with more invasive methods.

Correct Answer: B

Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.

Correct Answer: A

Rationale: Battery refers to the intentional touching of another person without consent, resulting in harm or offense. In this scenario, the nurse inserted the urinary catheter into the client's urethra without the client's consent, leading to an injury. This action constitutes battery as the nurse carried out a medical procedure without the client's permission, resulting in harm to the client. The client can sue the nurse for battery in this situation.