Nursing Elites

1. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?

• A. Insert a straight urinary catheter to drain the bladder.
• B. Scan the bladder for urinary retention.
• C. Palpate the suprapubic area for fetal head position.
• D. Test the fluid with a nitrazine strip.

Correct answer: D

Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.

2. A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?

• A. Schedule a visit with the healthcare provider today.
• B. Verify the compatibility of the administered Rho(D) immune globulin.
• C. Encourage the client to increase her intake of oral fluids.
• D. Instruct the client to maintain bedrest for 24 hours.

Correct answer: C

Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.

3. The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

• A. Assess cervical dilation.
• B. Change the client's position.
• C. Administer oxygen via facemask.
• D. Turn off the oxytocin infusion.

Correct answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

4. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Unilateral lower leg pain.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 bpm.
• D. Soft, spongy fundus.

Correct answer: C

Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.

5. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

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