Nursing Elites

1. During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?

• A. Leukorrhea
• B. Supine hypotension
• C. Periodic numbness of the fingers
• D. Decreased urine output

Correct answer: D

Rationale: During pregnancy, decreased urine output can be indicative of decreased renal perfusion and impaired fetal well-being. It can also be a sign of preeclampsia when associated with symptoms like increased blood pressure, proteinuria, and decreased fetal activity. Therefore, the nurse should promptly report this finding to the healthcare provider for further evaluation and management. Leukorrhea is a common finding in pregnancy and not typically concerning. Supine hypotension and periodic numbness of the fingers can be managed by changing positions or adjusting posture and are not as urgent as decreased urine output in this context.

2. When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?

• A. Vaginal bleeding
• B. Swelling of the ankles
• C. Heartburn after eating
• D. Lightheadedness when lying on back

Correct answer: A

Rationale: Vaginal bleeding during pregnancy is a concerning sign that could indicate serious complications like miscarriage or placental issues. Prompt reporting to the healthcare provider is crucial for timely evaluation and management to ensure the best outcomes for both the mother and the baby. Swelling of the ankles (choice B), heartburn after eating (choice C), and lightheadedness when lying on the back (choice D) are common discomforts during pregnancy but are not typically associated with serious complications that require immediate attention.

3. A client is 1 hour postpartum and the nurse observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

• A. Notify the healthcare provider.
• B. Increase the frequency of fundal massage.
• C. Encourage the client to empty their bladder.
• D. Document the findings and continue to monitor the client.

Correct answer: D

Rationale: In the postpartum period, the presence of lochia rubra and small clots along with a firm, midline fundus at the umbilicus is considered normal. In this situation, the appropriate action is to document the findings and continue to monitor the client. Changes in the amount and character of lochia, deviation of the fundus from the midline, or fundal height above or below the expected level may indicate a need for further intervention. Encouraging bladder emptying is important but not the priority in this scenario. Notify the healthcare provider if there are signs of abnormal postpartum bleeding or fundal abnormalities. Therefore, choice D is the correct answer. Choices A, B, and C are incorrect because at this stage, there are no signs of abnormality that require immediate notification of the healthcare provider, increased frequency of fundal massage, or immediate bladder emptying.

4. 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.

5. A healthcare professional is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the healthcare professional anticipate administering if magnesium sulfate toxicity is suspected?

• A. Nifedipine
• B. Pyridoxine
• C. Ferrous sulfate
• D. Calcium gluconate

Correct answer: D

Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity. In cases of magnesium sulfate toxicity, calcium gluconate is administered to counteract the effects of magnesium and restore calcium levels. Magnesium toxicity can lead to symptoms such as muscle weakness, respiratory depression, and cardiac arrhythmias. Calcium gluconate helps in reversing these effects by competing with magnesium and preventing its adverse manifestations. Nifedipine is a calcium channel blocker used for conditions like hypertension and angina, not for magnesium toxicity. Pyridoxine is vitamin B6 and is not the antidote for magnesium toxicity. Ferrous sulfate is an iron supplement and is not used to treat magnesium sulfate toxicity.

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