Nursing Elites

1. A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

• A. Place the client in a side-lying position.
• B. Assist the client to the bathroom to void.
• C. Obtain a prescription for IV oxytocin.
• D. Administer methylergonovine.

Correct answer: B

Rationale: In this scenario, the client's fundus findings indicate a distended bladder, which can lead to uterine atony. Assisting the client to the bathroom to void is essential as a distended bladder can inhibit the uterus from contracting normally. This action can help the uterus contract effectively and prevent complications such as postpartum hemorrhage. Placing the client in a side-lying position, obtaining a prescription for IV oxytocin, or administering methylergonovine are not the priority actions in this situation. Placing the client in a side-lying position might be indicated for fundal displacement, but it is not the priority here. Obtaining a prescription for IV oxytocin and administering methylergonovine are interventions for managing uterine atony, which is not the primary issue in this case; the priority is addressing the distended bladder.

2. A client is being discharged after childbirth. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?

• A. Scant, non-odorous white vaginal discharge
• B. Uterine cramping during breastfeeding
• C. Sore nipple with cracks and fissures
• D. Decreased response with sexual activity

Correct answer: C

Rationale: Sore nipples with cracks and fissures should be reported to the provider as this can indicate improper breastfeeding techniques or infection, which requires medical evaluation and intervention to prevent further complications such as mastitis or decreased milk supply. Scant, non-odorous white vaginal discharge is a normal finding postpartum. Uterine cramping during breastfeeding is also common due to oxytocin release. Decreased response with sexual activity may be expected at 4 weeks postpartum due to hormonal changes and fatigue, but it is not typically a concern that needs immediate medical attention.

3. A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?

• A. Using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and STIs.
• B. A diaphragm should be removed 2 hours after intercourse.
• C. Oral contraceptives can worsen a case of acne.
• D. A contraceptive patch is replaced once a month.

Correct answer: A

Rationale: The correct answer is A because using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and sexually transmitted infections (STIs). This statement demonstrates the client's understanding of the importance of proper condom use to maximize protection. Choice B is incorrect because a diaphragm should be left in place for at least 6 hours after intercourse to ensure contraceptive effectiveness. Choice C is incorrect as oral contraceptives are known to improve acne in some cases. Choice D is incorrect because a contraceptive patch is typically replaced weekly, not monthly.

4. When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?

• A. Count the fetal heart rate for 15 seconds to determine the baseline.
• B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
• C. Count the fetal heart rate after a contraction to determine baseline changes.
• D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.

Correct answer: C

Rationale: When discussing intermittent fetal heart monitoring, it is crucial to count the fetal heart rate after a contraction to determine baseline changes. This practice allows for the assessment of variations in the fetal heart rate pattern associated with uterine contractions. Monitoring the fetal heart rate after contractions provides valuable insights into fetal well-being and potential distress. Option A is incorrect because determining the baseline involves assessing the fetal heart rate over a more extended period. Option B is incorrect as auscultation every 5 minutes during the active phase of the first stage of labor is too frequent for intermittent monitoring. Option D is incorrect as auscultating the fetal heart rate every 30 minutes during the second stage of labor is too infrequent for proper monitoring of fetal well-being.

5. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

• A. Fetal attitude is in general flexion.
• B. Fetal lie is longitudinal.
• C. Maternal pelvis is gynecoid.
• D. Fetal position is persistent occiput posterior.

Correct answer: D

Rationale: The correct answer is D. In a persistent occiput posterior position, the baby's head presses against the mother's spine, causing prolonged labor and severe backache. This position can lead to difficulties in labor progress and increase discomfort for the mother. Choices A, B, and C are incorrect as they do not directly relate to the client's difficult, prolonged labor with severe backache. Fetal attitude, fetal lie, and maternal pelvis type may affect labor, but in this scenario, the persistent occiput posterior fetal position is the primary contributing cause for the client's symptoms.

Similar Questions