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. What advice is most important for a client in the first trimester of pregnancy experiencing nausea?

• A. Practice relaxation techniques when nausea begins.
• B. Increase fluid intake to 3 quarts daily.
• C. Avoid alcohol, caffeine, and smoking.
• D. Eliminate snacks between meals.

Correct answer: C

Rationale: During the first trimester of pregnancy, it is crucial to advise pregnant clients to avoid alcohol, caffeine, and smoking. These substances can worsen nausea and harm fetal development. By eliminating these substances, the client can help alleviate nausea and create a healthier environment for the developing fetus. Choices A, B, and D are not as critical in managing nausea during the first trimester. While relaxation techniques may help, avoiding harmful substances like alcohol, caffeine, and smoking takes precedence. Increasing fluid intake can be beneficial but not as crucial as avoiding harmful substances. Eliminating snacks between meals may not be necessary for all clients and is not directly related to managing nausea in the first trimester.

3. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?

• A. Turn the client to her left side
• B. Contact the healthcare provider
• C. Assess the fetal heart rate
• D. Check the cervical dilation

Correct answer: C

Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.

4. 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.

5. When a client delivers a viable infant but experiences excessive uncontrolled vaginal bleeding after the IV Pitocin infusion, what information is most important for the nurse to provide when notifying the healthcare provider?

• A. Maternal blood pressure
• B. Estimated blood loss
• C. Length of labor
• D. Amount of IV fluids administered

Correct answer: A

Rationale: In a situation where a client is experiencing excessive uncontrolled vaginal bleeding post-delivery, the most crucial information for the nurse to provide the healthcare provider is the maternal blood pressure. Maternal blood pressure can help assess the severity of the bleeding and guide immediate interventions to stabilize the client's condition. Estimated blood loss, length of labor, and amount of IV fluids administered are important pieces of information but in this scenario, maternal blood pressure takes precedence as it directly indicates the client's current hemodynamic status.

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