Nursing Elites

1. A healthcare professional is caring for a client who is 14 weeks of gestation. At which of the following locations should the healthcare professional place the Doppler device when assessing the fetal heart rate?

• A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
• B. Left Upper Abdomen
• C. Two fingerbreadths above the umbilicus
• D. Lateral at the Xiphoid Process

Correct answer: A

Rationale: At 14 weeks of gestation, the uterus is still relatively low in the abdomen. Placing the Doppler midline 2 to 3 cm above the symphysis pubis is appropriate for assessing the fetal heart rate. This location allows for better detection of the fetal heart tones as the uterus is at a lower position during this stage of pregnancy. Placing the Doppler on the left upper abdomen would not be ideal at 14 weeks gestation as the uterus is not yet at that level. Placing it two fingerbreadths above the umbilicus or lateral at the xiphoid process would also not be accurate for locating the fetal heart rate at this stage of gestation.

2. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?

• A. Uterine atony.
• B. Uterine inversion.
• C. Vaginal hematoma.
• D. Vaginal laceration.

Correct answer: A

Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.

3. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

• A. Assess the blood pressure for hypertension.
• B. Gently massage fundus every four hours.
• C. Observe for signs of uterine hemorrhage.
• D. Encourage direct contact with the infant.

Correct answer: C

Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.

4. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

• A. A client with a urinary output of 300 ml in 8 hours
• B. A client reporting abdominal cramping during breastfeeding
• C. A client receiving magnesium sulfate with absent deep tendon reflexes
• D. A client reporting lochia rubra requiring changing perineal pads every 3 hours

Correct answer: C

Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.

5. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?

• A. The client expels the placenta
• B. The client experiences gradual dilation of the cervix
• C. The client begins having regular contractions
• D. The client delivers the newborn

Correct answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.

Similar Questions