Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Assisting the mother into a hands-and-knees position should be prioritized to facilitate fetal rotation and optimize labor progress in the case of persistent occiput posterior fetal position. This position helps in promoting fetal rotation to a more favorable position for delivery by allowing the baby's head to move into the anterior position. It can help alleviate back pain and may help reduce the duration of labor. This simple maneuver can sometimes correct the malposition without the need for interventions like instrumental delivery. It is a non-invasive and effective technique that can be easily implemented by healthcare providers to support the progression of labor.

Correct Answer: A

Rationale: In the case of a woman in active labor with placenta previa, the priority nursing intervention is to prepare for an immediate cesarean section. Placenta previa is a condition in which the placenta covers part or all of the cervix, which can lead to severe bleeding during labor and delivery. The risk of hemorrhage is significant, making a cesarean section the safest option for both the mother and the baby in this situation. It is crucial to act promptly to prevent complications and ensure the well-being of both the mother and the baby. Administering intravenous oxytocin to augment labor or inserting a Foley catheter to monitor urine output would not address the immediate risk of hemorrhage associated with placenta previa. Implementing bed rest and continuous fetal monitoring may be part of the overall care plan but not the priority intervention in this urgent situation.

Correct Answer: D

Rationale: Before initiating any oxygen therapy, it is crucial for the nurse to first assess the patient's condition. This step allows the nurse to determine the patient's oxygen saturation levels, respiratory rate, lung sounds, and overall respiratory status. Understanding the patient's baseline condition helps in selecting the appropriate oxygen delivery method and flow rate that will best meet the patient's needs. Additionally, assessing the patient's condition allows the nurse to monitor the effectiveness of the oxygen therapy and make any necessary adjustments throughout the treatment process. Therefore, assessing the patient's condition is the necessary first step in providing safe and effective oxygen therapy.

Correct Answer: C

Rationale: Pericarditis is the inflammation of the pericardium, the sac surrounding the heart. Patients with pericarditis typically present with sharp chest pain that worsens with deep breathing, changes in body position, and coughing. The pain tends to improve when the patient leans forward. This characteristic symptom of pericarditis is known as "pleuritic" chest pain. In contrast, stable angina presents as predictable chest pain that occurs with exertion and is relieved by rest or medications. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion and is considered a medical emergency. Myocarditis involves inflammation of the heart muscle and may present with symptoms such as chest pain, but it does not typically have the characteristic of worsening with deep breathing or changes in body position.

Correct Answer: A

Rationale: Molluscum contagiosum is a viral skin infection caused by the poxvirus. It typically presents as multiple, flesh-colored, dome-shaped papules with a central umbilication (dimple or depression in the center) on the skin. These lesions are often found on the trunk and extremities and can persist for several months. Molluscum contagiosum is commonly seen in children but can also occur in adults, especially those with weakened immune systems. The lesions are usually asymptomatic but can become inflamed or itchy in some cases. Treatment options include observation, topical therapies, cryotherapy, or curettage.