Nursing Elites

1. Which intervention is most helpful in relieving postpartum uterine contractions or 'afterpains'?

• A. Lying prone with a pillow on the abdomen.
• B. Using a breast pump.
• C. Massaging the abdomen.
• D. Giving oxytocic medications.

Correct answer: A

Rationale: Lying prone with a pillow on the abdomen is the most helpful intervention in relieving postpartum uterine contractions or 'afterpains.' This position provides counter-pressure and support to the uterus, helping to alleviate discomfort and promote uterine involution. Choice B, using a breast pump, is not effective in relieving afterpains as it focuses on milk expression. Massaging the abdomen (Choice C) may help with discomfort but does not provide the same level of support as lying prone with a pillow. Giving oxytocic medications (Choice D) is not typically the first-line intervention for afterpains unless there are specific medical indications.

2. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

• A. Weak cry without tears.
• B. Bulging fontanel.
• C. Visible peristaltic wave.
• D. Palpable mass in the right upper quadrant.

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

3. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

• A. Turn off the oxytocin infusion.
• B. Reposition the fetal monitor transducers.
• C. Decrease the rate of the oxytocin infusion.
• D. Alert the charge nurse about the patient's condition.

Correct answer: A

Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.

4. A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?

• A. Itching sensation under the cast.
• B. Swelling of fingers with brisk capillary refill.
• C. Numbness and inability to move fingers.
• D. Visible bruising above the cast.

Correct answer: C

Rationale: Numbness and inability to move fingers are concerning findings that suggest potential nerve damage or compartment syndrome due to increased pressure within the cast. This requires immediate notification of the healthcare provider to prevent further complications or permanent damage.

5. The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

• A. Hemoglobin A1C.
• B. Postprandial blood glucose test.
• C. Oral glucose tolerance test.
• D. Fasting blood glucose.

Correct answer: C

Rationale: An abnormal oral glucose tolerance test result is indicative of gestational diabetes. This test is crucial in diagnosing gestational diabetes as it evaluates how well the body processes glucose after a sugary drink. Reporting abnormal results promptly allows for timely intervention and management to ensure the well-being of both the mother and the baby. The other options are not the primary tests used to diagnose gestational diabetes. Hemoglobin A1C is not recommended for diagnosing gestational diabetes as it reflects long-term glucose control. Postprandial blood glucose and fasting blood glucose tests are not as sensitive as the oral glucose tolerance test for diagnosing gestational diabetes.

Similar Questions