Nursing Elites

1.

• A. Recheck the client's temperature in 4 hours
• B. Administer glucocorticoids intramuscularly
• C. Assess the odor of the amniotic fluid
• D. Prepare the client for emergency cesarean section

Correct answer: C

Rationale:

2. A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?

• A. Saturated perineal pad in 30 minutes
• B. Deep tendon reflexes 4+
• C. Fundus at the level of the umbilicus
• D. Approximated edges of episiotomy

Correct answer: A

Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.

3. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L

• A. Respiratory acidosis
• B. Metabolic acidosis
• C. Metabolic alkalosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.

4. When admitting a client at 33 weeks of gestation with a diagnosis of placenta previa, which action should the nurse prioritize?

• A. Monitor vaginal bleeding
• B. Administer glucocorticoids
• C. Insert an IV catheter
• D. Apply an external fetal monitor

Correct answer: D

Rationale: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to potential bleeding. When admitting a client with placenta previa, the priority is to assess the fetal well-being. Applying an external fetal monitor helps in continuous monitoring of the fetal heart rate and ensures timely detection of any distress or changes in the fetal status, which is crucial in managing this condition. While monitoring vaginal bleeding is important, identifying fetal well-being takes precedence in this situation.

5. A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

• A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
• B. Observe an area of redness on the breast of a client who is 1 day postpartum.
• C. Monitor vital signs during admission of a client who has gestational hypertension.
• D. Change the perineal pad of a client who just transferred from labor and delivery.

Correct answer: A

Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.

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