Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: Prolonged rupture of membranes (>24 hours) increases the risk of intrauterine infection for both the mother and the fetus. When the amniotic sac has been ruptured for an extended period, there is a higher likelihood of bacteria entering the uterus, leading to chorioamnionitis (inflammation of the fetal membranes due to infection). Intrauterine infection can be dangerous for both the mother and fetus, potentially causing sepsis, preterm labor, and other complications. Therefore, it is crucial for the nurse to assess for signs and symptoms of infection in both the mother and fetus when managing a woman in active labor with prolonged rupture of membranes.

Correct Answer: A

Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.

Correct Answer: C

Rationale: If the nurse observes an unusual odor emanating from the surgical site during surgery, it is important to inform the surgeon immediately and assess for signs of infection. Changes in odor can sometimes be an early sign of infection, which requires prompt attention and intervention. By communicating with the surgeon and conducting a thorough assessment, the nurse can help ensure the timely detection and management of any potential complications, such as infection, that may be affecting the patient's surgical outcome. Prompt action in response to unusual observations is crucial to maintaining patient safety and well-being during surgical procedures.

Correct Answer: C

Rationale: When caring for patients with hyperbilirubinemia, the nursing care plan should focus on informing the significant others, preventing injury, and preventing complications. The primary goal in managing hyperbilirubinemia is to prevent complications associated with high bilirubin levels, such as kernicterus. Therefore, maintaining physiological homeostasis with bilirubin levels increasing would not be appropriate and should not be the focus of the nursing care plan. It is crucial to monitor and manage bilirubin levels to prevent adverse outcomes rather than allowing them to increase.