Nursing Elites

1. A pregnant woman in her first trimester is experiencing watery vaginal discharge. What should the nurse tell her?

• A. Inform her that it is normal.
• B. Advise her to see a doctor immediately.
• C. Suggest using panty liners.
• D. Suggest a change in diet.

Correct answer: A

Rationale: Informing the pregnant woman that watery vaginal discharge is normal during the first trimester is crucial to providing reassurance and reducing anxiety. This discharge, known as leukorrhea, is common during pregnancy due to increased estrogen levels and increased blood flow to the pelvic area. It helps maintain a healthy balance of bacteria in the vagina and protects the birth canal from infection. Advising the woman to see a doctor immediately may cause unnecessary alarm, while suggesting the use of panty liners can help manage the discharge comfortably. Suggesting a change in diet is not relevant to addressing watery vaginal discharge in this scenario.

2. A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

• A. Perform a sterile vaginal examination to determine dilatation.
• B. Determine fetal position by performing Leopold maneuvers.
• C. Assess the fetal heart rate and client's contraction pattern.
• D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.

Correct answer: C

Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.

3. What should the nurse recommend to a woman with mastitis?

• A. Apply heat to the affected area.
• B. Apply cold compresses to the affected area.
• C. Use a breast pump to express milk.
• D. Continue breastfeeding as usual.

Correct answer: A

Rationale: The nurse should recommend applying heat to the affected area for a woman with mastitis. Heat can help reduce pain and inflammation associated with mastitis by improving blood flow to the area and promoting healing.

4. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

5. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

• A. Patellar reflex 4+
• B. Blood pressure 158/80
• C. Four-hour urine output 240 ml
• D. Respirations 12/minute

Correct answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

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