Nursing Elites

1. A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?

• A. Moderate lochia rubra
• B. Excessive lochia serosa
• C. Light lochia rubra
• D. Scant lochia serosa

Correct answer: A

Rationale: The correct answer is 'Moderate lochia rubra.' On the second day postpartum, it is normal for lochia to be bright red and contain small clots, indicating moderate lochia rubra. This amount of bleeding is expected as the uterus continues to shed its lining after childbirth. Excessive lochia serosa, light lochia rubra, and scant lochia serosa do not accurately reflect the described scenario. Excessive lochia serosa is more characteristic of a later postpartum period, while light and scant lochia serosa are not consistent with the bright red color and small clots observed in this case.

2. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

• A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
• B. A fourth-degree episiotomy extends into the rectal area and is not recommended
• C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
• D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

3. A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?

• A. Epidural analgesia
• B. Naloxone hydrochloride
• C. Attention-focusing
• D. Pudendal nerve block

Correct answer: C

Rationale: Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.

4. A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

• A. 22/min
• B. 48/min
• C. 100/min
• D. 110/min

Correct answer: B

Rationale: The expected respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48 breaths per minute falls within this range, indicating normal respiratory function for a newborn. Choice A (22/min) is below the expected range, Choices C (100/min) and D (110/min) are above the expected range for a newborn's respiratory rate.

5. What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?

• A. It must be a comfort to know you have another child.
• B. I'm sad for you.
• C. There is usually something wrong with the baby.
• D. You will always have an angel in heaven.

Correct answer: B

Rationale: Option B, 'I'm sad for you,' is the most appropriate response for the nurse to make to the client who has experienced a perinatal death. This statement conveys empathy and compassion, acknowledging the client's grief and validating their emotions. It opens the door for the client to express their feelings and facilitates further communication and support from the nurse. Choices A, C, and D are not appropriate in this context. Choice A may come across as dismissive of the client's grief by redirecting the focus to another child. Choice C suggests blame or fault, which is not helpful or accurate in most cases of perinatal death. Choice D, while well-intentioned, may not be comforting to all clients and could impose a specific belief system on the client's experience.

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