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 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.

3. A client who is pregnant states that her last menstrual period was April 1st. What is the client's estimated date of delivery?

• A. January 8
• B. January 15
• C. February 8
• D. February 15

Correct answer: A

Rationale: To calculate the estimated date of delivery, add 7 days to the first day of the last menstrual period (April 1st), which gives April 8th. Then, count forward 9 months from April 8th, leading to January 8th as the estimated date of delivery. Choice A is correct. Choice B is incorrect because it is exactly 9 months from the last menstrual period without accounting for the additional 7 days. Choices C and D are incorrect as they fall in February, which is beyond the 9-month period from the last menstrual period.

4. During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?

• A. Apply palms of both hands to sides of the uterus
• B. Palpate the fundus of the uterus
• C. Grasp the lower uterine segment between thumb and fingers
• D. Stand facing the client's feet with fingertips outlining cephalic prominence

Correct answer: B

Rationale: Palpating the fundus of the uterus during Leopold maneuvers is crucial to identify the fetal lie. This technique allows the nurse to determine the position of the baby's back and locate the fetal heart sounds, aiding in assessing the fetal lie. Choices A, C, and D are incorrect as they do not directly relate to identifying the fetal lie during Leopold maneuvers. Applying palms to the sides of the uterus or grasping the lower uterine segment do not provide the necessary information about the fetal lie. Standing facing the client's feet and outlining cephalic prominence is more related to assessing the fetal presentation, not the fetal lie.

5. A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?

• A. Check the client's capillary refill.
• B. Massage the client's fundus.
• C. Insert an indwelling urinary catheter for the client.
• D. Prepare the client for a blood transfusion.

Correct answer: B

Rationale: In a client with uterine hypotonicity and postpartum hemorrhage, the priority is to address the risk of hypovolemic shock, which can lead to vital organ perfusion compromise and potentially death. Massaging the client's fundus helps to control bleeding by promoting uterine contraction and reducing blood loss, making it the nurse's priority intervention in this situation. Checking capillary refill may be important in assessing perfusion status but is not the priority over controlling the hemorrhage. Inserting an indwelling urinary catheter is not the priority in managing postpartum hemorrhage. Although preparing for a blood transfusion may be necessary, addressing the primary cause of bleeding by massaging the fundus takes precedence to stabilize the client's condition.

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