Adult Health Nursing Test Banks

Correct Answer: D

Rationale: During the active phase of labor, a cervical dilation of 6 cm and regular contractions lasting 60 seconds each, occurring every 3 minutes indicate good progress in labor. The nurse should continue to monitor the progress closely by assessing the mother's vital signs, fetal heart rate, and the pattern of contractions. It is important to provide support and encouragement to the mother, continue with comfort measures, and be prepared to assist with the delivery when the cervix is fully dilated. This stage of labor is focused on active dilation and effacement of the cervix, and it is not yet time for the mother to push or for the nurse to administer oxytocin to augment labor.

Correct Answer: A

Rationale: Shoulder dystocia is an obstetric emergency where one of the baby's shoulders becomes impacted behind the mother's pubic bone after the head delivers. This can lead to compression of the umbilical cord and compromise fetal oxygenation. The most critical nursing intervention in managing shoulder dystocia is applying suprapubic pressure to dislodge the impacted shoulder and allow for delivery of the baby. By gently pushing downwards on the mother's abdomen just above the pubic bone, the shoulder can be released, and the baby can be delivered successfully. This intervention should be prioritized to prevent potential complications for both the mother and the baby. Episiotomy may be considered if necessary, but it is secondary to addressing the shoulder dystocia. Oropharyngeal airway insertion and administering magnesium sulfate are not indicated in the immediate management of shoulder dystocia.

Correct Answer: C

Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).

Correct Answer: C

Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.

Correct Answer: B

Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.