Nursing Elites

1. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

• A. Evaluate the firmness of the uterus.
• B. Initiate oxygen therapy via a non-rebreather mask.
• C. Administer oxytocin infusion.
• D. Obtain a type and crossmatch.

Correct answer: A

Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

2. During a client's active labor, a healthcare provider notes that the presenting part is at 0 station. What is the correct interpretation of this clinical finding?

• A. The fetal head is in the left occiput posterior position.
• B. The largest fetal diameter has passed through the pelvic outlet.
• C. The posterior fontanel is palpable.
• D. The lowermost portion of the fetus is at the level of the ischial spines.

Correct answer: D

Rationale: At 0 station, the lowermost portion of the fetus is at the level of the ischial spines, indicating that the presenting part of the baby has engaged in the pelvis. This position is a significant milestone in labor progress and suggests that the baby is descending into the birth canal for delivery. Choices A, B, and C are incorrect. Choice A refers to the fetal head position, choice B describes the largest fetal diameter passing through the pelvic outlet (which is not related to station), and choice C refers to the palpability of the posterior fontanel (which is not relevant to station in labor).

3. A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?

• A. Check the client's capillary refill.
• B. Massage the client's fundus.
• C. Insert an indwelling urinary catheter for the client.
• D. Prepare the client for a blood transfusion.

Correct answer: B

Rationale: In a client with uterine hypotonicity and postpartum hemorrhage, the priority is to address the risk of hypovolemic shock, which can lead to vital organ perfusion compromise and potentially death. Massaging the client's fundus helps to control bleeding by promoting uterine contraction and reducing blood loss, making it the nurse's priority intervention in this situation. Checking capillary refill may be important in assessing perfusion status but is not the priority over controlling the hemorrhage. Inserting an indwelling urinary catheter is not the priority in managing postpartum hemorrhage. Although preparing for a blood transfusion may be necessary, addressing the primary cause of bleeding by massaging the fundus takes precedence to stabilize the client's condition.

4. During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?

• A. Vertex
• B. Shoulder
• C. Breech
• D. Mentum

Correct answer: C

Rationale: The correct answer is C: "Breech." The RSA position indicates that the fetus is in a breech presentation. In a breech presentation, the buttocks or feet are positioned to be delivered first, which can impact the mode of delivery and require close monitoring during labor and birth. Choice A (Vertex) refers to the head-first presentation, which is considered the normal and most common presentation for birth. Choice B (Shoulder) does not represent a specific fetal presentation. Choice D (Mentum) refers to the chin presentation, which is also not relevant in this scenario.

5. A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

• A. Palpate the client's uterine fundus.
• B. Assist the client to a bedpan to urinate.
• C. Prepare to administer oxytocic medication.
• D. Increase the client's fluid intake.

Correct answer: A

Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. A boggy uterus that is not well contracted may indicate uterine atony, which can lead to postpartum hemorrhage. Palpating the fundus and massaging it if it is boggy helps to promote contractions and reduce bleeding, making it the most critical intervention to address the potential underlying issue. Assisting the client to a bedpan to urinate, preparing to administer oxytocic medication, or increasing the client's fluid intake are not the immediate priorities in this scenario compared to assessing and addressing the uterine fundus status.

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