Nursing Elites

1. A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?

• A. By checking the client's urine for blood
• B. By checking the client's stool for blood
• C. By checking the client's urine for a decrease in output
• D. By checking the client's bowel movements for diarrhea

Correct answer: B

Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

2. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

• A. Reporting the finding to the healthcare provider immediately
• B. Helping the woman stay in bed and rest
• C. Documenting the finding
• D. Performing active and passive range-of-motion exercises

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

3. What is the most appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus?

• A. Insertion of a Foley catheter.
• B. In-and-out catheter specimen for urinalysis.
• C. A voided urine specimen for urinalysis.
• D. A urologist consult.

Correct answer: D

Rationale: A urologist consult is the most appropriate intervention for a client with visible blood at the urethral meatus and suspected genitourinary trauma. This specialist can evaluate the extent of the trauma and provide the necessary treatment. Foley catheter insertion (Choice A) and in-and-out catheter specimen for urinalysis (Choice B) are contraindicated in the presence of genitourinary trauma as they can worsen the injury. While a voided urine specimen for urinalysis (Choice C) may be ordered by the physician, it does not address the specific management needed for genitourinary trauma. Therefore, a urologist consult is the best option in this scenario.

4. The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?

• A. "I am nervous about how painful labor will be."?
• B. "I need to review my finances and make sure I am prepared to care for a child."?
• C. "I hate this nausea that I've been having for a week."?
• D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?

Correct answer: D

Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.

5. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?

• A. Insert a gloved finger into the mother's vagina to feel for cord compression
• B. Position the mother so that her hips are elevated
• C. Notify the registered nurse
• D. Perform a vaginal examination on the mother

Correct answer: B

Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.

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