Some postpartum mothers will experience difficulty voiding because of the edema and trauma of the perineum. Which PRIORITY nursing measures stimulate the sensation of voiding?

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Foundations and Adult Health Nursing Study Guide Answers Questions

Question 1 of 9

Some postpartum mothers will experience difficulty voiding because of the edema and trauma of the perineum. Which PRIORITY nursing measures stimulate the sensation of voiding?

Correct Answer: B

Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.

Question 2 of 9

A woman in active labor has a prolonged second stage with inadequate expulsive efforts. What nursing intervention is appropriate to facilitate fetal descent?

Correct Answer: B

Rationale: In the scenario of a woman in active labor experiencing a prolonged second stage with inadequate expulsive efforts, the appropriate nursing intervention to facilitate fetal descent would be to apply fundal pressure. Fundal pressure, or applying pressure on the upper abdomen just above the uterine fundus, can help in directing the fetal head downwards and aiding in the descent through the birth canal. It is important to note that fundal pressure should be applied carefully and with proper technique to prevent excessive force that could potentially harm the mother or the baby. Encouraging the mother to push forcefully during contractions can be helpful, but the addition of fundal pressure can provide extra assistance in cases of inadequate progress. Immediate cesarean section may be considered if other interventions are unsuccessful or if there are concerns for fetal distress. Administering intravenous magnesium sulfate for uterine relaxation is not indicated in this situation.

Question 3 of 9

What should be the INITIAL S'TEP in the process of change for the senior nurse

Correct Answer: D

Rationale: The initial step in the process of change for the senior nurse should be to identify the inefficiency that needs improvement or correction. Before setting goals, planning strategies, or identifying solutions, it is essential to first pinpoint the specific area or aspect that requires change. By identifying the inefficiency, the senior nurse can gain a clear understanding of the root cause of the issue and focus efforts on addressing it effectively. This step lays the foundation for the rest of the change process by providing a specific target for improvement.

Question 4 of 9

During a patient assessment, the nurse observes signs of distress and discomfort. What action should the nurse take to address the patient's needs?

Correct Answer: C

Rationale: The correct action for the nurse to take when observing signs of distress and discomfort in a patient during assessment is to offer emotional support and actively listen to the patient's concerns. Ignoring the patient's distress may lead to worsening of the patient's condition and can be detrimental to the patient's well-being. Documenting the findings and informing the healthcare provider later is important but should not be the immediate response when a patient is in distress. Administering pain medication without further assessment is also not appropriate as the nurse needs to understand the underlying cause of the distress before providing appropriate interventions. Offering emotional support and actively listening to the patient's concerns can help the nurse understand the patient's needs, provide comfort, and potentially address the root cause of the distress.

Question 5 of 9

In taking the patient's history from the mother, the nurse should ask the mother information related to the daughters' __________.

Correct Answer: C

Rationale: The nurse should ask the mother information related to their daughter's menarche. Menarche refers to the first occurrence of menstruation in a girl, which is an important milestone in her development. By inquiring about the daughter's menarche, the nurse can gather essential information about the daughter's reproductive health, growth, and development. This allows the nurse to assess whether the daughter's menstrual cycle is regular and if there are any concerns related to her reproductive health. Understanding the daughter's menarche history is vital in providing appropriate healthcare and support for her.

Question 6 of 9

In the universal health law, which of the following are the government agencies that are considered as "key players" in its implementation?

Correct Answer: B

Rationale: In the universal health law, the government agencies that are considered as "key players" in its implementation are the Department of Health (DOH), Local Government Units (LGUs), and the Philippine Health Insurance Corporation (PhilHealth).

Question 7 of 9

During surgery, the nurse notices an abnormal heart rhythm on the patient's cardiac monitor. What is the nurse's priority action?

Correct Answer: B

Rationale: The nurse's priority action when noticing an abnormal heart rhythm on the patient's cardiac monitor during surgery is to assess the patient's vital signs and symptoms. This is important because the nurse needs to gather more information about the patient's condition to determine the significance of the abnormal rhythm and the potential impact on the patient's health. By assessing the vital signs and symptoms, the nurse can obtain a more complete picture of the situation and make informed decisions about the next steps in caring for the patient. Once the assessment is done, appropriate actions such as administering medication or notifying the anesthesiologist can be taken based on the findings.

Question 8 of 9

The lecturer reminded the committee members that bias is an influence that distorts study results. In quantitative research, which will eliminate bias?

Correct Answer: B

Rationale: In quantitative research, randomness plays a crucial role in eliminating bias. Random sampling ensures that every individual or element in the population has an equal chance of being selected for the study. This helps in reducing the possibility of bias creeping into the results due to selective sampling or favoritism towards certain groups. By using random sampling methods, researchers can increase the generalizability of their findings and have a higher level of confidence that the results are unbiased and representative of the entire population. Therefore, randomness is a key mechanism to eliminate bias in quantitative research studies.

Question 9 of 9

Friendly but professional overtures have finally made Marlene open up her circumstances to the nurse, including their financial difficulty. What has been established at this time?

Correct Answer: B

Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.

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