Nursing Elites

1. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

• A. Increase the intravenous fluid to 150 ml/hr.
• B. Call the healthcare provider.
• C. Encourage the client to void.
• D. Administer ibuprofen 800 milligrams by mouth.

Correct answer: C

Rationale: Encouraging the client to void is the priority action in this scenario. A distended bladder can prevent the uterus from contracting properly, leading to increased bleeding and a high uterine fundus. By encouraging the client to void, the nurse can help the uterus contract effectively, reducing bleeding. Increasing intravenous fluids or administering ibuprofen would not address the immediate concern of a distended bladder affecting uterine contraction. While it may be necessary to involve the healthcare provider, addressing the bladder distention promptly is crucial to prevent further complications.

2. A newborn is being assessed by a nurse who was born post-term. Which of the following findings should the nurse expect?

• A. Nails extending over tips of fingers
• B. Large deposits of subcutaneous fat
• C. Pale, translucent skin
• D. Thin covering of fine hair on shoulders and back

Correct answer: A

Rationale: Post-term newborns often have longer nails that extend over the tips of their fingers due to the extended gestation period. This occurs because the baby continues to grow in utero past the typical 40 weeks of gestation. Choices B, C, and D are incorrect as large deposits of subcutaneous fat, pale translucent skin, and a thin covering of fine hair on shoulders and back are not typically associated with post-term newborns. Longer nails are a common finding in post-term newborns due to the prolonged time spent in the womb, allowing for more nail growth compared to infants born at term.

3. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?

• A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
• B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
• C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
• D. Record the findings on the chart. They are within normal limits.

Correct answer: D

Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.

4. Examination reveals that the laboring client's cervix is dilated to 2 centimeters, 70% effaced with the presenting part at -2 station. The client tells the nurse, 'I need my epidural now, this hurts.' The nurse's response to the client is based on which information?

• A. The client will need to be catheterized before the epidural can be administered.
• B. Administering an epidural at this point would slow down the labor process.
• C. The client should be dilated to at least 8 centimeters before receiving an epidural.
• D. The baby needs to be at a zero station before an epidural can be administered.

Correct answer: B

Rationale: Administering an epidural too early in labor, especially at 2 cm dilation, can slow down the progress of labor. It is usually recommended to wait until labor is more established. Choice A is incorrect because catheterization is not a prerequisite for epidural administration. Choice C is incorrect as waiting until 8 cm dilation is not a standard requirement for epidural administration. Choice D is incorrect because the baby's station being at zero is not a strict criterion for epidural administration.

5. A client who is receiving prenatal care is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?

• A. Group B strep culture
• B. 1-hour glucose tolerance test
• C. Rubella titer
• D. Blood type and Rh

Correct answer: B

Rationale: The correct answer is B: 1-hour glucose tolerance test. At around 24-28 weeks of gestation, a pregnant individual is typically screened for gestational diabetes. The 1-hour glucose tolerance test helps in identifying elevated blood sugar levels during pregnancy. Choice A, Group B strep culture, is not typically performed at the 24-week appointment but later in the third trimester to screen for Group B streptococcus colonization. Choice C, Rubella titer, is usually checked early in pregnancy to determine immunity to rubella. Choice D, Blood type and Rh, is important for determining the client's blood type and Rh status, but it is usually done earlier in pregnancy and not specifically at the 24-week appointment.

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