Nursing Elites

1. A client in labor at 40 weeks of gestation has saturated two perineal pads in the past 30 min. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

• A. Examination to determine cervical status
• B. A magnesium sulfate infusion
• C. Initiation of pushing
• D. Preparation for cesarean birth

Correct answer: D

Rationale: In the scenario described, the client is experiencing heavy vaginal bleeding, which is concerning for placenta previa. The appropriate nursing action in this situation is to prepare for a cesarean birth. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. It is crucial to avoid vaginal examinations or initiation of pushing as these actions can exacerbate bleeding. A magnesium sulfate infusion is not indicated in the management of placenta previa. Therefore, the priority intervention is to prepare for a cesarean birth to ensure the safety of the mother and the baby.

2. A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

• A. Elevate the head of the bed to at least 30�.
• B. Apply restraints if the client becomes agitated.
• C. Administer pantoprazole as prescribed.
• D. Reposition the endotracheal tube to the opposite side of the mouth daily.

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30� helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.

3. A client with preterm labor is being admitted. The nurse anticipates a prescription by the provider for which of the following medications?

• A. Prostaglandin E2
• B. Indomethacin
• C. Methylergonovine
• D. Oxytocin

Correct answer: B

Rationale: Indomethacin is used to delay premature labor by inhibiting uterine contractions. Prostaglandin E2, Methylergonovine, and Oxytocin are not typically used to manage preterm labor. Prostaglandin E2 can be used for cervical ripening and labor induction. Methylergonovine is used to prevent or control postpartum hemorrhage. Oxytocin is used for labor induction and augmentation of labor in term pregnancies.

4. A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?

• A. Saturated perineal pad in 30 minutes
• B. Deep tendon reflexes 4+
• C. Fundus at the level of the umbilicus
• D. Approximated edges of episiotomy

Correct answer: A

Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.

5. A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

• A. A client who experienced a cesarean birth 4 hours ago and reports pain
• B. A client who has preeclampsia with a BP of 138/90 mm Hg
• C. A client who experienced a vaginal birth 24 hours ago and reports no bleeding
• D. A client who is scheduled for discharge following a laparoscopic tubal ligation

Correct answer: A

Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.

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