Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: In documenting procedures, it is essential to record information that is relevant to the specific procedure done. Recording the date (A), lot number (C), and needle gauge (D) are critical details that provide important context and traceability for the procedure performed. The date helps to keep track of when the procedure was conducted. The lot number is essential for tracking the specific batch of materials used in the procedure. The needle gauge is important for ensuring the appropriate equipment is used for the procedure. However, recording the manufacturer (B) is not necessary for documenting the procedures as it does not directly impact the quality or traceability of the procedure itself.

Correct Answer: C

Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.

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: A

Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine

Correct Answer: B

Rationale: In the scenario of a woman in active labor experiencing a prolonged second stage with inadequate expulsive efforts, the appropriate nursing intervention to facilitate fetal descent would be to apply fundal pressure. Fundal pressure, or applying pressure on the upper abdomen just above the uterine fundus, can help in directing the fetal head downwards and aiding in the descent through the birth canal. It is important to note that fundal pressure should be applied carefully and with proper technique to prevent excessive force that could potentially harm the mother or the baby. Encouraging the mother to push forcefully during contractions can be helpful, but the addition of fundal pressure can provide extra assistance in cases of inadequate progress. Immediate cesarean section may be considered if other interventions are unsuccessful or if there are concerns for fetal distress. Administering intravenous magnesium sulfate for uterine relaxation is not indicated in this situation.