Nursing Elites

1. 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.

2. A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

• A. A client who is at 38 weeks of gestation and reports a cough and fever
• B. A client who has missed a period and reports vaginal spotting
• C. A client who is at 14 weeks of gestation and reports nausea and vomiting
• D. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

Correct answer: D

Rationale:

3. When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?

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

Correct answer: A

Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.

4. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following comp

• A. Placenta previa
• B. Prolapsed cord
• C. Incompetent cervix
• D. Abruptio placentae

Correct answer: D

Rationale:

5. A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

• A. Administer oxygen via nasal cannula
• B. Offer option to view products of conception
• C. Instruct the client to increase potassium-rich foods in the diet
• D. Maintain the client on bed rest

Correct answer: B

Rationale: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.

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