Nursing Elites

1. A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

• A. Palpate the client's uterine fundus.
• B. Assist the client to a bedpan to urinate.
• C. Prepare to administer oxytocic medication.
• D. Increase the client's fluid intake.

Correct answer: A

Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. A boggy uterus that is not well contracted may indicate uterine atony, which can lead to postpartum hemorrhage. Palpating the fundus and massaging it if it is boggy helps to promote contractions and reduce bleeding, making it the most critical intervention to address the potential underlying issue. Assisting the client to a bedpan to urinate, preparing to administer oxytocic medication, or increasing the client's fluid intake are not the immediate priorities in this scenario compared to assessing and addressing the uterine fundus status.

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 nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?

• A. Seeking an immunization against rubella early in pregnancy.
• B. Receiving prophylactic treatment for cytomegalovirus if detected during pregnancy.
• C. Clients should avoid crowded places during pregnancy.
• D. Clients should avoid consuming undercooked meat while pregnant.

Correct answer: D

Rationale: The correct answer is D. To prevent TORCH infections during pregnancy, it is essential for clients to avoid consuming undercooked meat, as it can be a potential source of toxoplasmosis. This infection, along with others in the TORCH group, can pose risks to the fetus, making it crucial for pregnant individuals to follow proper food safety practices. Choices A, B, and C are incorrect because seeking an immunization against rubella, receiving prophylactic treatment for cytomegalovirus, and avoiding crowded places are not directly related to preventing TORCH infections through food safety measures.

4. 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.

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

• A. Administer oxygen via nasal cannula.
• B. Offer the 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: In cases of inevitable abortion, offering the option to view products of conception can assist in emotional healing and closure for the client. This can provide a sense of acknowledgment and closure for the loss experienced, aiding in the grieving process. Administering oxygen via nasal cannula (choice A) is not directly related to the emotional and psychological support needed during an inevitable abortion. Instructing the client to increase potassium-rich foods (choice C) may not be a priority in this situation. Maintaining the client on bed rest (choice D) may be indicated in some cases but does not address the emotional aspect of the situation.

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