Nursing Elites

1. The healthcare provider is providing postpartum care to a client who had a vaginal delivery. Which finding would require further assessment?

• A. Perineal swelling
• B. Moderate lochia serosa
• C. Headache unrelieved by analgesics
• D. Breast engorgement

Correct answer: C

Rationale: A headache unrelieved by analgesics can be a sign of a serious condition such as preeclampsia, which is a life-threatening condition characterized by high blood pressure and often protein in the urine. Prompt assessment and intervention are crucial to prevent complications for both the mother and baby.

2. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. In addition to administering high-flow oxygen, treatment should include:

• A. treating for shock and uterine massage during transport.
• B. uterine massage and transport.
• C. placing her on her left side and transport.
• D. internal vaginal pads and treating for shock during transport.

Correct answer: A

Rationale: In this scenario, the mother is showing signs of postpartum hemorrhage with increased heart rate, diaphoresis, and mild vaginal bleeding. The correct approach involves treating for shock by addressing hypovolemia and providing uterine massage to help control bleeding. Administering high-flow oxygen is essential. Therefore, the most appropriate option is to treat for shock and perform uterine massage during transport to manage the postpartum hemorrhage effectively.

3. How should you assist with the delivery of the baby's head?

• A. Grasping each side of the baby's head and gently pulling to facilitate delivery.
• B. Placing your fingers on the bony part of the skull and applying gentle pressure.
• C. Carefully rotating the baby's head to face up during delivery.
• D. Placing the palm of your hand firmly against the back of the baby's skull.

Correct answer: B

Rationale: To assist with the delivery of the baby's head, the correct technique involves placing your fingers on the bony part of the skull and applying gentle pressure. This method helps guide the baby's head through the birth canal safely and effectively. Choices A, C, and D are incorrect. Grasping and pulling the baby's head, rotating the head, or placing the palm of your hand against the back of the baby's skull can potentially cause harm or complications during delivery.

4. Which pain assessment tool is most appropriate for a 3-month-old hospitalized with a fractured femur?

• A. FLACC scale
• B. Poker chip tool
• C. Number scale
• D. Visual analog scale

Correct answer: A

Rationale: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is specifically designed for nonverbal patients like infants and young children. It assesses pain based on observable behaviors such as facial expressions, leg movement, activity level, cry, and the ability to be consoled. In this case, a 3-month-old infant who is unable to communicate verbally would best be assessed using the FLACC scale to determine the level of pain experienced due to a fractured femur. The Poker chip tool, Number scale, and Visual analog scale are not suitable for nonverbal infants and young children as they rely on self-reporting or cognitive abilities that are not yet developed at this age.

5. The caregiver is teaching a new parent about signs of adequate breastfeeding. Which statement by the parent indicates understanding?

• A. My baby should have a bowel movement once a week.
• B. My baby should wet at least six diapers a day.
• C. My baby should feed for 5 minutes on each breast.
• D. My baby should sleep through the night without waking up to feed.

Correct answer: B

Rationale: Wetting at least six diapers a day is a key indicator of adequate breastfeeding as it shows that the baby is properly hydrated and receiving enough milk.

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