Correct Answer: A

Rationale: Ear pain is a hallmark symptom of otitis media, caused by inflammation and pressure from fluid buildup in the middle ear.
Choice B is incorrect because clear ear drainage is not typical; purulent or bloody drainage may occur if the eardrum ruptures.
Choice C is incorrect because a fever of 37.2°C is not significant; otitis media often causes higher fevers (e.g., >38°
C) in acute cases.
Choice D is incorrect because otitis media typically causes hearing loss due to fluid in the middle ear, not improved hearing.

Correct Answer: B

Rationale: Monitoring for chest pain or palpitations is critical with modafinil, a stimulant used for narcolepsy, as it can cause cardiovascular side effects like tachycardia or hypertension.
Choice A is correct but not the priority; modafinil is typically taken in the morning to promote wakefulness, but safety monitoring is more critical.
Choice C is incorrect because modafinil is more likely to cause weight loss, not weight gain, due to its stimulant effects.
Choice D is incorrect because modafinil can be taken with or without food; a high-fat meal may delay absorption but is not necessary.

Correct Answer: A

Rationale: The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain. The other choices are contraindicated for the following reasons:
Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
Choice E: Placing a blanket roll under the client's knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.

Correct Answer: C

Rationale: Monitoring for muscle weakness, which may indicate hypokalemia, is critical, as furosemide is a loop diuretic that can cause potassium loss, increasing the risk of arrhythmias in heart failure clients.
Choice A is wrong because clients with heart failure should limit sodium intake to reduce fluid retention, not increase it, to prevent exacerbation of heart failure.
Choice B is wrong because taking furosemide at bedtime is not advised; it should be taken in the morning to avoid nocturia and disrupted sleep due to its diuretic effect.
Choice D is wrong because increasing fluid intake is not recommended for heart failure clients, as it can worsen fluid overload; fluid intake should be guided by the provider based on the client's condition.

Correct Answer: C

Rationale: Uterine contractions lasting 90 seconds indicate adequate contraction strength and duration, suggesting that the oxytocin infusion is effective, but the nurse should assess if the frequency and cervical progression support increasing the rate to achieve active labor (contractions every 2-3 minutes).
Choice A is wrong because contractions every 4 minutes may indicate early labor, and increasing the oxytocin rate may be premature without assessing cervical change or contraction strength.
Choice B is wrong because a fetal heart rate of 140/min with moderate variability is normal and does not directly indicate the need to adjust the oxytocin rate.
Choice D is wrong because a cervical dilation of 2 cm after 6 hours of labor suggests protracted labor, but increasing the oxytocin rate should be based on a comprehensive assessment, including contraction pattern and fetal status, not dilation alone.