Nursing Elites

1. A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

• A. Administer oxygen via nasal cannula
• B. Offer 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: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.

2. 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.

3. A healthcare provider in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the provider the presence of intra-abdominal bleeding?

• A. Chvostek's sign
• B. Cullen's sign
• C. Chadwick's sign
• D. Goodell's sign

Correct answer: B

Rationale: Cullen's sign is the presence of periumbilical ecchymosis indicating intra-abdominal bleeding, which can be associated with a ruptured ectopic pregnancy. Chvostek's sign is a facial spasm related to hypocalcemia. Chadwick's sign is a bluish discoloration of the cervix, vagina, and labia during early pregnancy. Goodell's sign is a softening of the cervix in early pregnancy.

4. A client at 37 weeks of gestation with placenta previa asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

• A. There is an increased risk of introducing infection.
• B. This could initiate preterm labor.
• C. This could result in profound bleeding.
• D. There is an increased risk of rupture of the membranes.

Correct answer: C

Rationale: Performing an internal examination in a client with placenta previa can lead to significant bleeding due to the proximity of the placenta to the cervical os. This bleeding can be severe and potentially life-threatening. Therefore, it is crucial to avoid any unnecessary manipulation that could disrupt the delicate balance and lead to hemorrhage.

5. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following comp

• A. Placenta previa
• B. Prolapsed cord
• C. Incompetent cervix
• D. Abruptio placentae

Correct answer: D

Rationale:

Similar Questions