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. When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?

• A. Vaginal bleeding
• B. Swelling of the ankles
• C. Heartburn after eating
• D. Lightheadedness when lying on back

Correct answer: A

Rationale: Vaginal bleeding during pregnancy is a concerning sign that could indicate serious complications like miscarriage or placental issues. Prompt reporting to the healthcare provider is crucial for timely evaluation and management to ensure the best outcomes for both the mother and the baby. Swelling of the ankles (choice B), heartburn after eating (choice C), and lightheadedness when lying on the back (choice D) are common discomforts during pregnancy but are not typically associated with serious complications that require immediate attention.

3. A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

• A. Placenta previa
• B. Prolapsed cord
• C. Incompetent cervix
• D. Abruptio placentae

Correct answer: D

Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall, which can cause continuous abdominal pain and vaginal bleeding. In this scenario, the client's symptoms of sudden abdominal pain and vaginal bleeding are indicative of abruptio placentae, which requires immediate medical attention to prevent potential complications for both the client and the fetus. Placenta previa is characterized by painless vaginal bleeding in the third trimester, not sudden abdominal pain. Prolapsed cord presents with visible umbilical cord protruding from the vagina and is not associated with abruptio placentae symptoms. Incompetent cervix typically manifests as painless cervical dilation in the second trimester, not sudden abdominal pain and bleeding as seen in abruptio placentae.

4. A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?

• A. This test screens for neural tube defects and other developmental abnormalities in the fetus.
• B. It assesses various markers of fetal well-being.
• C. This test identifies an Rh incompatibility between the mother and fetus.
• D. It is a screening test for spinal defects in the fetus.

Correct answer: A

Rationale: The maternal serum alpha-fetoprotein (MSAFP) test is performed around 15-18 weeks of gestation to screen for neural tube defects and other developmental abnormalities in the fetus, not to assess fetal lung maturity, markers of fetal well-being, or Rh incompatibility between the mother and fetus. Choice A is the correct answer as it accurately reflects the purpose of the MSAFP test. Choices B, C, and D are incorrect because they do not align with the primary goal of this screening test.

5. A client with pregestational type 1 diabetes mellitus is being taught by a nurse about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should aim to maintain my fasting blood glucose between 100 and 120.
• B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or higher.
• C. I will continue taking my insulin if I experience nausea and vomiting.
• D. I will avoid exercise if my blood glucose exceeds 250.

Correct answer: C

Rationale: The correct answer is C. It is essential for a client with pregestational type 1 diabetes mellitus to continue taking insulin as prescribed even if they experience nausea and vomiting. This is crucial to prevent fluctuations in blood glucose levels that could lead to serious complications. Choice A is incorrect because the fasting blood glucose target for pregnant women with diabetes is usually lower. Choice B is incorrect as engaging in exercise when blood glucose is high is not recommended. Choice D is incorrect as avoiding exercise is not the appropriate approach when blood glucose levels are elevated.

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