Nursing Elites

1. A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?

• A. Encourage the client to perform Kegel exercises.
• B. Encourage the client to move to the left lateral position.
• C. Ask the client to rate her pain.
• D. Assist the client to the bathroom to void.

Correct answer: D

Rationale: A displaced and boggy fundus in a postpartum client typically indicates a full bladder, which can impede uterine contractions and increase the risk of postpartum hemorrhage. Assisting the client to the bathroom to void helps ensure the bladder is empty, aiding the fundus to contract and reducing the risk of complications. Encouraging Kegel exercises, changing positions, or assessing pain would not directly address the issue of the boggy fundus caused by a full bladder.

2. A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

• A. Place the client in a side-lying position.
• B. Assist the client to the bathroom to void.
• C. Obtain a prescription for IV oxytocin.
• D. Administer methylergonovine.

Correct answer: B

Rationale: In this scenario, the client's fundus findings indicate a distended bladder, which can lead to uterine atony. Assisting the client to the bathroom to void is essential as a distended bladder can inhibit the uterus from contracting normally. This action can help the uterus contract effectively and prevent complications such as postpartum hemorrhage. Placing the client in a side-lying position, obtaining a prescription for IV oxytocin, or administering methylergonovine are not the priority actions in this situation. Placing the client in a side-lying position might be indicated for fundal displacement, but it is not the priority here. Obtaining a prescription for IV oxytocin and administering methylergonovine are interventions for managing uterine atony, which is not the primary issue in this case; the priority is addressing the distended bladder.

3. During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?

• A. Acrocyanosis of hands and feet
• B. Anterior fontanel soft and level
• C. Plantar creases cover 2/3 of sole
• D. Vernix caseosa in inguinal creases

Correct answer: C

Rationale: Plantar creases covering 2/3 of the sole is an important physical characteristic used to assess gestational age in a newborn. This finding is significant because as gestational age advances, the plantar creases cover a larger portion of the sole. It is a valuable clue to the healthcare provider in determining the newborn's maturity level. Choices A, B, and D are incorrect as they do not specifically relate to gestational age assessment. Acrocyanosis and vernix caseosa are common findings in newborns but are not directly used for determining gestational age. The softness and level of the anterior fontanel can provide information about intracranial pressure but are not directly related to gestational age assessment.

4. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

• A. Check the client's temperature.
• B. Observe for uterine contractions.
• C. Administer Rho(D) immune globulin.
• D. Monitor the fetal heart rate (FHR).

Correct answer: D

Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.

5. While caring for a newborn, a nurse auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

• A. Ask another nurse to verify the heart rate.
• B. Document this as an expected finding.
• C. Call the provider to further assess the newborn.
• D. Prepare the newborn for transport to the NICU.

Correct answer: B

Rationale: An apical heart rate of 130/min is within the expected range for a newborn. It is not necessary to seek verification from another nurse, call the provider for further assessment, or prepare for NICU transport based on this heart rate. Documenting the heart rate as an expected finding is the appropriate action in this situation as it falls within the normal range for a newborn's heart rate.

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