Nursing Elites

1. A healthcare professional is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition?

• A. No alteration in menses
• B. Transvaginal ultrasound indicating a fetus in the uterus
• C. Blood progesterone greater than the expected reference range
• D. Report of severe shoulder pain

Correct answer: D

Rationale: Severe shoulder pain is a common finding in clients with a ruptured ectopic pregnancy due to referred pain from diaphragmatic irritation caused by blood in the abdominal cavity. This pain is known as Kehr's sign and is often experienced in the shoulder due to irritation of the phrenic nerve. Choices A, B, and C are incorrect. A ruptured ectopic pregnancy typically presents with symptoms such as abdominal pain, vaginal bleeding, and signs of shock, rather than no alteration in menses, a fetus in the uterus, or elevated blood progesterone levels.

2. A client is being educated by a healthcare provider about the changes she should expect when planning to become pregnant. Identify the correct sequence of maternal changes. A. Amenorrhea B.Lightening C. Goodell's sign D. Quickening

• A. A,B,C,D
• B. D,B,A,C
• C. A,D,B,C
• D. A,C,D,B

Correct answer: D

Rationale: The correct sequence of maternal changes during pregnancy is as follows: Amenorrhea (absence of menstrual periods), Goodell's sign (softening of the cervix), Quickening (first fetal movements felt by the mother), and Lightening (baby descending into the pelvis). These changes occur at different stages of pregnancy and are important indicators of fetal development and maternal adaptation. Choice A is correct as it is the initial change indicating possible pregnancy. Choices B, C, and D follow in the correct order of occurrence during pregnancy. Choices B, C, and D are incorrect as they do not follow the correct sequence of maternal changes.

3. A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?

• A. Apply an ice pack to the affected area.
• B. Offer a warm sitz bath.
• C. Provide a squeeze bottle of antiseptic solution.
• D. Place a hot pack on the perineum.

Correct answer: A

Rationale: The correct answer is to apply an ice pack to the affected area. Ice packs help reduce swelling, inflammation, and provide pain relief post-episiotomy. Applying heat, as in a hot pack or warm sitz bath, can increase swelling and discomfort. Providing antiseptic solution in a squeeze bottle is not the first-line intervention for managing episiotomy pain, as the priority is pain relief and comfort.

4. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

• A. Evaluate the firmness of the uterus.
• B. Initiate oxygen therapy via a non-rebreather mask.
• C. Administer oxytocin infusion.
• D. Obtain a type and crossmatch.

Correct answer: A

Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

5. During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?

• A. It is used to stimulate uterine contractions.
• B. It will decrease the incidence of uterine contractions.
• C. It lulls the fetus to sleep.
• D. It awakens a sleeping fetus.

Correct answer: D

Rationale: The acoustic vibration device is utilized during a nonstress test to awaken a sleeping fetus. This action helps ensure more accurate test results by eliciting fetal movements and heart rate accelerations, which are indicators of fetal well-being. Choices A, B, and C are incorrect because the primary purpose of the acoustic vibration device during a nonstress test is not to stimulate uterine contractions, decrease uterine contractions, or lull the fetus to sleep. Instead, it is specifically used to awaken a sleeping fetus to assess fetal well-being.

Similar Questions