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 is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L

• A. Respiratory acidosis
• B. Metabolic acidosis
• C. Metabolic alkalosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.

3. A client is being assessed for postpartum infection. Which of the following findings should indicate to the healthcare provider that the client requires further evaluation for endometritis?

• A. Localized area of breast tenderness
• B. Pelvic pain
• C. Vaginal discharge with foul odor
• D. Hematuria

Correct answer: B

Rationale: Pelvic pain is a common symptom of endometritis, which is an infection of the uterine lining. It is an important finding that warrants further evaluation. Localized area of breast tenderness may indicate mastitis, vaginal discharge with a foul odor could suggest a vaginal infection, and hematuria points towards a urinary tract issue, but they are not specific to endometritis.

4. A client in labor at 40 weeks of gestation has saturated two perineal pads in the past 30 min. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

• A. Examination to determine cervical status
• B. A magnesium sulfate infusion
• C. Initiation of pushing
• D. Preparation for cesarean birth

Correct answer: D

Rationale: In the scenario described, the client is experiencing heavy vaginal bleeding, which is concerning for placenta previa. The appropriate nursing action in this situation is to prepare for a cesarean birth. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. It is crucial to avoid vaginal examinations or initiation of pushing as these actions can exacerbate bleeding. A magnesium sulfate infusion is not indicated in the management of placenta previa. Therefore, the priority intervention is to prepare for a cesarean birth to ensure the safety of the mother and the baby.

5. A client at 37 weeks of gestation with placenta previa asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

• A. There is an increased risk of introducing infection.
• B. This could initiate preterm labor.
• C. This could result in profound bleeding.
• D. There is an increased risk of rupture of the membranes.

Correct answer: C

Rationale: Performing an internal examination in a client with placenta previa can lead to significant bleeding due to the proximity of the placenta to the cervical os. This bleeding can be severe and potentially life-threatening. Therefore, it is crucial to avoid any unnecessary manipulation that could disrupt the delicate balance and lead to hemorrhage.

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