Correct Answer: C

Rationale: In a primiparous patient who complains of unrelieved perineal pain on the first postpartum day, Nurse Kayla should assess for a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can cause significant pain and discomfort. It can be a result of trauma during delivery or due to a blood vessel rupture. This condition requires prompt assessment and intervention to prevent complications such as infection or excessive bleeding. Vaginal laceration would typically be identified during the delivery process and would have been repaired by the healthcare provider. History of drug abuse, while important to know for overall patient care, is not as relevant in this immediate postpartum pain assessment. Puerperal infection usually presents with other signs such as fever, foul-smelling discharge, and uterine tenderness, which are not mentioned in this scenario.

Correct Answer: C

Rationale: An amniotic fluid embolism is a rare and life-threatening complication during labor and delivery. It occurs when amniotic fluid or fetal cells enter the maternal circulation, triggering a rapid immune response that can lead to cardiovascular collapse and respiratory failure. The priority nursing intervention for a woman in active labor diagnosed with an amniotic fluid embolism is to initiate cardiopulmonary resuscitation (CPR) to support her vital functions and circulation. Providing immediate CPR can help sustain her until further medical interventions can be implemented. Administering oxygen and preparing for a cesarean section may be necessary but should occur after CPR is initiated to stabilize the woman's condition. Inserting an indwelling urinary catheter is not the priority in this emergency situation, as maintaining adequate cardiac and respiratory function takes precedence.

Correct Answer: D

Rationale: Negligence is the failure to take proper care in doing something, which results in harm or injury to someone else. In this scenario, the client falling out of bed because side rails were not used indicates a lack of proper care or attention by the staff or caregiver responsible for the client. It shows a failure to protect the client from harm, which aligns with the definition of negligence. This situation does not fit the definitions of a felony, battery, or assault.

Correct Answer: C

Rationale: By endorsing a detergent product on a TV commercial wearing a mini skirt and a plunging neckline shirt, Ms. Sanchez is violating the code of ethics for nurses. The code of ethics for nurses includes provisions that promote professionalism, respect, and integrity in the nursing profession. As a new nursing graduate, Ms. Sanchez has a responsibility to uphold the dignity and reputation of the nursing profession, and endorsing a product in a manner that may compromise her professional image goes against these principles. Nurses are expected to maintain a professional appearance and behavior that reflects positively on the profession and does not undermine public trust in their abilities as healthcare providers. Therefore, Ms. Sanchez's actions in this scenario are in violation of the code of ethics for nurses.

Correct Answer: A

Rationale: When collecting evidence from a rape victim, it is important to handle the victim's clothing properly to preserve any potential evidence. The preferred method is to remove the clothing and place them in a paper bag. Paper bags are used in order to prevent the alteration or degradation of any DNA evidence that may be present on the clothing. Paper bags allow the clothing to breathe and prevent the growth of mold or other contaminants that can occur in plastic bags or trash bags. Additionally, paper bags help preserve trace evidence such as fibers or hairs that may be crucial in the investigation of the case. It is essential to handle and store the clothing correctly to maintain the integrity of the evidence for the investigation and potential prosecution.