Nursing Elites

1. 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.

2. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?

• A. Reduce cerebral edema and lower intracranial pressure
• B. Avert hypotension and septic shock
• C. Prevent cardiac arrhythmias and heart failure
• D. Promote kidney perfusion and normal blood pressure

Correct answer: A

Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.

3. The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?

• A. Palpate the client’s bladder.
• B. Check the pH of the vaginal fluid.
• C. Review the fetal heart rate pattern.
• D. Determine cervical dilation.

Correct answer: D

Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications. While checking the client's bladder may be important to ensure it's not distended, determining cervical dilation takes precedence in this scenario. Checking the pH of the vaginal fluid is not relevant in this situation, and reviewing the fetal heart rate pattern, although important, is not the first action to take when the client expresses the need to go to the bathroom.

4. 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.

5. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

• A. Use a sterile item to tie off the umbilical cord.
• B. Provide privacy for the woman.
• C. Reassure the husband and try to keep him calm.
• D. Put the newborn to breast.

Correct answer: D

Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.

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