To provide protection against antibody production, RhoGam should be given within 72 hours. Options B, C, and D: These durations are too late to provide antibody protection. RhoGam can also be given during pregnancy.
The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Option A: Notifying the physician might be necessary but not before turning the client to her side. Option B: Starting an IV is not necessary at this time. Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly.
The symptoms of painless vaginal bleeding are consistent with placenta previa. Option B: Cervical check for dilation is contraindicated because this can increase the bleeding. Option C: Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. Option D: A detailed history can be done later.
For a child with epiglottitis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Options A, C, and D: Intravenous supplies, fluid, and oxygen will not treat an obstruction.
The staging of Wilm’s tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual non hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
The recessive Duchenne’s gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Option B: The client’s pain should be assessed, but this is not life-threatening. Options C and D: When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used.
The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. Options B, C, and D: A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required.
The client with a hip fracture will most likely have misalignment. Options A, C, and D: All fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.
Low morale of staff is an internal factor that affects only the unit. All the rest of the options emanate from the top executive or from outside the institution.
Majority rule involves dividing the house and the highest vote wins.1/2 + 1 is a majority.
A system used to deliver care. In the 70’s it was termed as methods of patient assignment; in the early 80’s it was called modalities of patient care then patterns of nursing care in the 90’s until recently authors called it nursing care systems.
Functional nursing is focused on tasks and activities and not on the holistic care of the patients
This option follows the framework of the nursing process at the same time applies the management process of planning, organizing, directing and controlling
The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively.
In setting priorities for a group of patients, those who need the most care should be number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care ca be attended to later or even delegated to assistive personnel according to rules on delegation.
