Nursing Elites

1. At 12 hours after the birth of a healthy infant, the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. Which action should the nurse take?

• A. Check the suprapubic area for distention
• B. Inform the client to take a warm sitz bath
• C. Inspect the client's perineal and rectal areas
• D. Apply a fresh pad and check in 1 hour

Correct answer: C

Rationale: In this situation, the mother's complaint of constant vaginal pressure along with a firm fundus and moderate rubra lochia indicates a potential perineal injury or hematoma. The correct action for the nurse to take is to inspect the client's perineal and rectal areas to assess for any signs of trauma or hematoma. Checking the suprapubic area for distention (Choice A) is not the priority here since the symptoms suggest a perineal issue. Advising a warm sitz bath (Choice B) may not address the underlying issue and could potentially worsen any existing trauma. Applying a fresh pad and checking in 1 hour (Choice D) does not address the need for immediate assessment of the perineal and rectal areas in response to the reported symptoms.

2. During which of the following periods does the development of arms and legs occur in a pregnancy?

• A. Development of the lungs
• B. Development of the heart
• C. Development of arms and legs
• D. Development of the stomach

Correct answer: C

Rationale: The correct answer is C. The development of arms and legs occurs during the critical period of the fourth to eighth weeks of pregnancy. This timeframe is crucial for the formation of limbs and other key body parts. Choices A, B, and D are incorrect because the development of the lungs, heart, and stomach respectively occurs at different stages of fetal development and is not primarily associated with the fourth to eighth weeks of pregnancy.

3. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

• A. Increase the intravenous fluid to 150 ml/hr.
• B. Call the healthcare provider.
• C. Encourage the client to void.
• D. Administer ibuprofen 800 milligrams by mouth.

Correct answer: C

Rationale: Encouraging the client to void is the priority action in this scenario. A distended bladder can prevent the uterus from contracting properly, leading to increased bleeding and a high uterine fundus. By encouraging the client to void, the nurse can help the uterus contract effectively, reducing bleeding. Increasing intravenous fluids or administering ibuprofen would not address the immediate concern of a distended bladder affecting uterine contraction. While it may be necessary to involve the healthcare provider, addressing the bladder distention promptly is crucial to prevent further complications.

4. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?

• A. Dilation of the cervix.
• B. Descent of the fetus to –2 station.
• C. Rupture of the amniotic membranes.
• D. Increase in bloody show.

Correct answer: A

Rationale: During the first stage of labor, effective uterine contractions lead to cervical dilation. Dilation of the cervix is a key indicator that uterine contractions are progressing labor. Descent of the fetus to -2 station (Choice B) is related to the fetal position in the pelvis and not a direct indicator of uterine contraction effectiveness. Rupture of the amniotic membranes (Choice C) signifies the rupture of the fluid-filled sac surrounding the fetus and does not directly reflect uterine contraction effectiveness. An increase in bloody show (Choice D) can be a sign of impending labor, but it is not a direct indicator of uterine contraction effectiveness.

5. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

• A. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.”
• B. “The drug keeps your baby from requiring too much sedation.”
• C. “Surfactant is used to reduce episodes of periodic apnea.”
• D. “Your baby needs this medication to fight a possible respiratory tract infection.”

Correct answer: A

Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby’s lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.

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