The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?

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Question 1 of 9

The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?

Correct Answer: C

Rationale: The correct answer is C: Umbilicus. The nurse begins assessing the uterine fundus at the level of the umbilicus as it is a standard reference point for postpartum fundal height measurement. This location allows for consistency and accuracy in tracking the descent of the uterus back into the pelvic cavity. Starting at the umbilicus also helps in monitoring the involution process and prevents potential errors in fundal height assessment. Symphysis pubis (A) is too low and not typically used as a reference point for uterine fundal assessment. Midline (B) is vague and does not provide a specific anatomical landmark. Sides of the abdomen (D) do not give a standardized starting point for measuring the uterine fundus, leading to potential variability in assessment.

Question 2 of 9

A woman in active labor demonstrates signs of uterine inertia, with weak and irregular contractions contributing to slow cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?

Correct Answer: A

Rationale: In cases of uterine inertia, where weak and irregular contractions are causing slow cervical dilation during labor, administering intravenous oxytocin can help augment contractions and stimulate more effective progress. Oxytocin is a hormone that naturally stimulates uterine contractions and is commonly used in clinical settings to induce or enhance labor. By increasing the strength and frequency of contractions, oxytocin can help address uterine inertia and promote efficient cervical dilation to facilitate the progress of labor. It is important to monitor the response to oxytocin carefully to avoid complications such as hyperstimulation of the uterus, which can lead to fetal distress.

Question 3 of 9

Which of the following clinical manifestations is most indicative of acute respiratory distress syndrome (ARDS)?

Correct Answer: C

Rationale: Rationale: - ARDS is characterized by severe hypoxemia and respiratory distress. - Tachypnea is a hallmark sign of ARDS due to the body's compensatory mechanism to increase oxygenation. - Hypoxemia refractory to supplemental oxygen signifies the inability to improve oxygen levels despite intervention. - Choices A, B, and D do not align with typical manifestations of ARDS, as they do not directly reflect severe hypoxemia or respiratory distress.

Question 4 of 9

A patient undergoing mechanical ventilation in the ICU develops acute exacerbation of chronic obstructive pulmonary disease (COPD). What intervention should the healthcare team prioritize to manage the patient's exacerbation?

Correct Answer: A

Rationale: The correct answer is A: Initiate non-invasive positive pressure ventilation (NIPPV). This intervention is prioritized as it helps improve oxygenation and ventilation in COPD exacerbation without the need for invasive mechanical ventilation, reducing the risk of ventilator-associated complications. NIPPV also decreases the work of breathing and can prevent the need for intubation. Administering bronchodilator medications (B) is important in COPD exacerbation but may not address the immediate need for ventilatory support. Endotracheal intubation (C) should be reserved for cases of respiratory failure not responding to NIPPV. Chest physiotherapy (D) may be beneficial in some cases but is not the first-line intervention for managing acute COPD exacerbation.

Question 5 of 9

At which stage of Lewin ' s planned change indicates the nurse identifying, planning, and implementing appropriate strategies ensuring that driving forces exceed restraining forces?

Correct Answer: C

Rationale: The correct answer is C: unfreezing. Unfreezing is the initial stage in Lewin's planned change model where individuals become open to change by recognizing the need for it. During this stage, the nurse identifies the need for change, plans strategies to implement it, and works on overcoming resistance by ensuring that the driving forces (reasons for change) outweigh the restraining forces (barriers to change). Refreezing (A) is the final stage where the changes are reinforced and integrated into the organization. Movement (B) is the stage where actual change occurs, and in activism (D) is not a recognized stage in Lewin's model.

Question 6 of 9

When the lecture presentation was finished, the CI proceeded with the _______.

Correct Answer: C

Rationale: The correct answer is C because an open forum to solicit questions related to the topic under discussion is a common practice after a lecture presentation. This allows for clarification and deeper understanding. Choice A is incorrect as evaluation usually comes after the lecture. Choice B is incorrect because the Q&A portion typically focuses on the lecture content only. Choice D is incorrect as cracking humorous anecdotes is not a standard practice after a lecture.

Question 7 of 9

Norse Sophie checks the gauge of the patient ' s intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood?

Correct Answer: B

Rationale: The correct answer is B: 20-Gauge. The smaller the gauge number, the larger the diameter of the catheter. Blood transfusions typically require a larger catheter size to prevent hemolysis and ensure proper flow. A 20-Gauge catheter is larger than 22-Gauge, 18-Gauge, and 12-Gauge, making it suitable for administering blood. 22-Gauge is too small and can cause hemolysis, 18-Gauge is smaller than the recommended size for blood transfusions, and 12-Gauge is too large and can cause damage to the vein.

Question 8 of 9

Which of the following situation is an example of incongruent message?

Correct Answer: C

Rationale: Step 1: Incongruent message occurs when verbal and nonverbal communication do not align. Step 2: Choice C states "When what the nurse says and does do not agree," indicating a lack of alignment. Step 3: This inconsistency can lead to confusion or mistrust in communication. Step 4: Choices A, B, and D all describe situations with alignment between words and actions, making them congruent. Summary: Choice C is correct as it exemplifies incongruent communication, while Choices A, B, and D are incorrect as they describe congruent messages.

Question 9 of 9

A woman in active labor demonstrates signs of prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

Correct Answer: B

Rationale: When a woman in active labor exhibits signs of prolonged second stage, such as ineffective pushing efforts and slow fetal descent, one of the maternal conditions that should be considered is pelvic floor dysfunction. The pelvic floor muscles play a crucial role in supporting the uterus, bladder, and rectum. If these muscles are weak or dysfunctional, it can lead to difficulty in pushing effectively and impede the descent of the fetus through the birth canal. This can result in prolonged labor and increase the risk of complications for both the mother and the baby. Therefore, assessing for pelvic floor dysfunction is important in addressing the abnormal labor pattern and providing appropriate interventions to support the progress of labor.

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