Nursing Elites

1. 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.

2. A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

• A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions
• B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
• C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes
• D. A client who has a diagnosis of preeclampsia reports epigastric pain and an unresolved headache

Correct answer: D

Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.

3. A client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?

• A. The client is carrying more than one fetus
• B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid
• C. An excessive amount of amniotic fluid is present
• D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor

Correct answer: C

Rationale: Polyhydramnios refers to the presence of an excessive amount of amniotic fluid around the fetus. This condition can result from various causes, such as maternal diabetes, fetal anomalies, or genetic disorders. It can lead to complications during pregnancy and delivery, such as preterm labor, placental abruption, or fetal malpresentation. Understanding this diagnosis is crucial for providing appropriate care and monitoring to ensure the best outcomes for both the mother and the fetus.

4. 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.

5. A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)

• A. Severe dyspnea
• B. Decreased level of consciousness
• C. Headache
• D. Nausea

Correct answer: D

Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.

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