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 who is 6 hours postpartum and Rh-negative has an Rh-positive newborn. The client asks why an indirect Coombs test was ordered. Which of the following is an appropriate response by the healthcare provider?

• A. It determines if kernicterus will occur in the newborn.
• B. It detects Rh-negative antibodies in the newborn's blood.
• C. It detects Rh-positive antibodies in the mother's blood.
• D. It determines the presence of maternal antibodies in the newborn's blood.

Correct answer: C

Rationale: The indirect Coombs test is performed to detect Rh-positive antibodies in the mother's blood. In cases where the mother is Rh-negative and the baby is Rh-positive, the mother may develop antibodies against the baby's blood cells, which can lead to hemolytic disease of the newborn. Choice A is incorrect because kernicterus is a complication of severe jaundice, not directly assessed by the indirect Coombs test. Choice B is incorrect as the test aims to detect Rh-positive antibodies, not Rh-negative antibodies in the newborn's blood. Choice D is incorrect as the test is focused on detecting antibodies in the mother's blood, not the newborn's.

3. When a client states, 'My water just broke,' what is the nurse's priority intervention?

• A. Perform Nitrazine testing.
• B. Assess the fluid.
• C. Check cervical dilation.
• D. Begin FHR monitoring.

Correct answer: D

Rationale: The correct answer is D: Begin FHR monitoring. The priority intervention when a client's water breaks is to assess the fetal well-being due to the risk of umbilical cord prolapse. Monitoring the fetal heart rate (FHR) will help the nurse ensure the fetus's well-being. Performing Nitrazine testing (choice A) or assessing the fluid (choice B) may provide information about the rupture of membranes but does not directly address fetal well-being. Checking cervical dilation (choice C) is important but not the priority when the client's water has broken.

4. What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?

• A. It must be a comfort to know you have another child.
• B. I'm sad for you.
• C. There is usually something wrong with the baby.
• D. You will always have an angel in heaven.

Correct answer: B

Rationale: Option B, 'I'm sad for you,' is the most appropriate response for the nurse to make to the client who has experienced a perinatal death. This statement conveys empathy and compassion, acknowledging the client's grief and validating their emotions. It opens the door for the client to express their feelings and facilitates further communication and support from the nurse. Choices A, C, and D are not appropriate in this context. Choice A may come across as dismissive of the client's grief by redirecting the focus to another child. Choice C suggests blame or fault, which is not helpful or accurate in most cases of perinatal death. Choice D, while well-intentioned, may not be comforting to all clients and could impose a specific belief system on the client's experience.

5. A newborn is small for gestational age (SGA). Which of the following findings is associated with this condition?

• A. Moist skin
• B. Protruding abdomen
• C. Gray umbilical cord
• D. Wide skull sutures

Correct answer: D

Rationale: Wide skull sutures are a common finding in newborns who are small for gestational age (SGA) due to reduced intrauterine growth. This occurs because the skull bones do not grow at the same rate as the brain, leading to wider sutures. Moist skin, a protruding abdomen, and a gray umbilical cord are not typically associated with being small for gestational age.

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