Nursing Elites

1. A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?

• A. Saturated perineal pad in 30 minutes
• B. Deep tendon reflexes 4+
• C. Fundus at the level of the umbilicus
• D. Approximated edges of episiotomy

Correct answer: A

Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.

2. A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. Following an examination, the provider informs the client that the fetus has died, indicating a:

• A. Incomplete miscarriage
• B. Missed miscarriage
• C. Inevitable miscarriage
• D. Complete miscarriage

Correct answer: B

Rationale: A missed miscarriage, also known as a silent or delayed miscarriage, occurs when the embryo or fetus has died, but no bleeding or contractions have occurred to expel it from the uterus. In this scenario, the client's experiencing slight occasional vaginal bleeding over the past two weeks indicates a missed miscarriage as the fetus has died, but the body has not recognized the loss or expelled the products of conception.

3. A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

• A. Administer oxygen via nasal cannula
• B. Offer option to view products of conception
• C. Instruct the client to increase potassium-rich foods in the diet
• D. Maintain the client on bed rest

Correct answer: B

Rationale: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.

4. A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

• A. Elevate the head of the bed to at least 30�.
• B. Apply restraints if the client becomes agitated.
• C. Administer pantoprazole as prescribed.
• D. Reposition the endotracheal tube to the opposite side of the mouth daily.

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30� helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.

5. A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9�C (102�F). Besides notifying the provider, which of the following is an appropriate nursing action?

• A. Recheck the client's temperature in 4 hours
• B. Administer glucocorticoids intramuscularly
• C. Assess the odor of the amniotic fluid
• D. Prepare the client for emergency cesarean section

Correct answer: C

Rationale: In a pregnant woman with a temperature of 38.9�C (102�F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.

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