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 young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?

• A. Itching sensation under the cast.
• B. Swelling of fingers with brisk capillary refill.
• C. Numbness and inability to move fingers.
• D. Visible bruising above the cast.

Correct answer: C

Rationale: Numbness and inability to move fingers are concerning findings that suggest potential nerve damage or compartment syndrome due to increased pressure within the cast. This requires immediate notification of the healthcare provider to prevent further complications or permanent damage.

3. At 40-weeks gestation, a client presents to the obstetrical floor indicating that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. Which information is most important for the nurse to obtain?

• A. Color and consistency of fluid.
• B. Estimated amount of fluid.
• C. Any odor noted when membranes ruptured.
• D. Time the membranes ruptured.

Correct answer: A

Rationale: The color and consistency of the amniotic fluid are crucial to assess for the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can suggest fetal compromise and the need for further evaluation and monitoring. The estimated amount of fluid is less critical than assessing for meconium. While noting any odor when the membranes ruptured may provide some information, it is not as crucial as assessing for meconium. The time the membranes ruptured is important for documenting the timeline but does not directly impact immediate patient care like assessing for fetal distress.

4. The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

• A. Insert an internal fetal monitor.
• B. Assess for cervical changes q1h.
• C. Monitor bleeding from IV sites.
• D. Perform Leopold's maneuvers.

Correct answer: C

Rationale: Monitoring for bleeding from IV sites is the priority intervention in this situation. The dark red vaginal bleeding, uterine tension, and other assessment findings suggest a potential placental abruption. Monitoring bleeding from IV sites can help detect coagulopathy, which may be associated with placental abruption. Options A, B, and D are not the most appropriate interventions in this scenario. Inserting an internal fetal monitor, assessing for cervical changes, and performing Leopold's maneuvers are not the priority actions when dark red vaginal bleeding and uterine tension are present, indicating a potential emergency situation.

5. A postpartum client who is Rh-negative refuses to receive RhoGAM after the delivery of an infant who is Rh-positive. Which information should the nurse provide this client?

• A. RhoGAM prevents maternal antibody formation for future Rh-positive babies.
• B. RhoGAM is not necessary unless all of her pregnancies are Rh-positive.
• C. The Rh-positive factor from the fetus threatens her blood cells.
• D. The mother should receive RhoGAM when the baby is Rh-negative.

Correct answer: A

Rationale: The correct answer is A. RhoGAM is administered to Rh-negative individuals after exposure to Rh-positive blood to prevent the development of antibodies that could harm future Rh-positive babies during subsequent pregnancies. By refusing RhoGAM after the delivery of an Rh-positive infant, the mother risks developing these antibodies, which could lead to hemolytic disease in future pregnancies with Rh-positive babies. Therefore, it is crucial for the nurse to explain to the client that receiving RhoGAM prevents the formation of maternal antibodies against Rh-positive blood, safeguarding the health of future babies. Choices B, C, and D are incorrect. Choice B is incorrect because RhoGAM is necessary after exposure to Rh-positive blood, regardless of the Rh status of future pregnancies. Choice C is incorrect as it does not accurately convey the purpose of RhoGAM administration. Choice D is incorrect because RhoGAM is specifically given after exposure to Rh-positive blood, not when the baby is Rh-negative.

Similar Questions