Who among the following is the BEST to sign an informed consent during a surgical procedure of a child at the health center?

Correct Answer: D

Rationale: In this scenario, the mother, who is 35 years old and illiterate but with on and off seizure, is the best candidate to sign the informed consent for a surgical procedure for the child. The mother is the primary caregiver and decision-maker for the child in most cases, and her relationship to the child is most crucial in this situation. Despite her illiteracy, she can still comprehend the importance of the procedure for her child's well-being. Additionally, accommodations can be made for an illiterate person to sign the consent form by using an "X" as a signature. It is important that the person signing the consent form has a clear understanding of the risks and benefits involved, as well as the ability to make decisions in the best interest of the child.

Correct Answer: D

Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.

Correct Answer: C

Rationale: Breach of duty is the element of malpractice that occurs when the nurse does not act as a reasonable, prudent person would have acted in a similar circumstance. This means that the nurse failed to uphold the standard of care expected in their practice. In a malpractice case, it must be proven that the nurse breached their duty of care towards the patient by not providing the expected level of skill and care that another reasonable nurse in the same situation would have provided.

Correct Answer: C

Rationale: Medico-legal charts are typically stored for a minimum of 10 years after the case is closed to ensure compliance with legal requirements and to provide a comprehensive record of the medical care provided. This duration allows for potential future reference, follow-up treatment, or legal purposes that may arise within the specified timeframe. It is important to maintain these records for an extended period to protect both the patient's rights and the healthcare provider's accountability. Additionally, storing medico-legal charts for 10 years aligns with standard retention practices in the healthcare industry.

Correct Answer: A

Rationale: Establishing a regular routine can be very helpful in stabilizing the mental state of parents. Consistency and structure in day-to-day activities can provide a sense of predictability and control, which can help reduce anxiety and stress. By having a routine, the parents can feel more organized, efficient, and better equipped to manage their responsibilities and emotions. Additionally, a regular routine can promote better sleep patterns, healthier habits, and overall well-being. This measure is practical, achievable, and can have positive effects on the mental stability of Nurse Lailanie's parents.

Correct Answer: A

Rationale: Calcium carbonate should be taken with meals because it requires the presence of stomach acid to be properly absorbed. Taking it with meals helps ensure optimal absorption and effectiveness as a phosphate binder in patients with chronic kidney disease. Administering calcium carbonate on an empty stomach may lead to gastrointestinal side effects such as upset stomach, bloating, and constipation. Taking it with a full glass of water is also recommended to help prevent potential gastrointestinal issues and to ensure proper hydration. Crushing tablets before administration is not advised unless specifically instructed by a healthcare provider, as it can alter the drug's release and absorption properties.

Correct Answer: B

Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.

Correct Answer: C

Rationale: Before initiating hydrotherapy for pain relief during labor, the nurse's priority action should be to assess the maternal and fetal conditions to determine if the mother is eligible for this form of pain management. It is essential to ensure that hydrotherapy is safe and appropriate for the specific situation. Assessing the maternal condition includes evaluating factors such as the stage of labor, maternal and fetal well-being, and any medical conditions that could impact the use of hydrotherapy. This assessment helps to identify any contraindications or risks that may affect the mother and baby during hydrotherapy. By conducting a thorough assessment, the nurse can make an informed decision about whether hydrotherapy is suitable for the woman in labor.

Correct Answer: C

Rationale: The APCAR (Appearance, Pulse, Grimace, Activity, Respiration) score is used to evaluate a newborn's condition in the first few minutes after birth. This assessment typically occurs within the first 1 to 3 minutes after the baby is born. The score helps healthcare providers quickly assess the baby's overall well-being and determine if any immediate interventions or further monitoring are necessary.