Nursing Elites

1. A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)

• A. Breast tenderness
• B. Urinary frequency
• C. Epistaxis
• D. All of the above

Correct answer: D

Rationale: During early pregnancy, common discomforts include breast tenderness due to hormonal changes, urinary frequency caused by increased blood flow to the kidneys, and epistaxis (nosebleeds) due to increased blood volume and hormonal changes. Educating the client about these discomforts helps them understand what to expect during this stage. Choice D, 'All of the above,' is the correct answer because all the listed findings are common discomforts experienced during early pregnancy. Choices A, B, and C are individually correct as well, as breast tenderness, urinary frequency, and epistaxis are all common discomforts that pregnant individuals may encounter.

2. A client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?

• A. This is due to an increase in blood volume.
• B. This is due to pressure from the uterus on the diaphragm.
• C. This is due to the weight of the uterus on the vena cava.
• D. This is due to increased cardiac output.

Correct answer: C

Rationale: Maternal hypotension during pregnancy is often caused by the weight of the uterus pressing on the vena cava when the client is lying on her back, which reduces blood flow to the heart. This compression can lead to a decrease in blood pressure and subsequent symptoms of hypotension. Choice A is incorrect because an increase in blood volume typically leads to increased blood pressure rather than hypotension. Choice B is incorrect as pressure from the uterus on the diaphragm is not a common cause of maternal hypotension. Choice D is incorrect because increased cardiac output would not directly cause maternal hypotension.

3. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?

• A. Evidence of a possible vaginal hematoma
• B. An indication of a cervical or perineal laceration
• C. A normal postpartum discharge of lochia
• D. Abnormally excessive lochia rubra flow

Correct answer: C

Rationale: The nurse should interpret this data as a normal postpartum discharge of lochia. Lochia is the normal vaginal discharge after childbirth, and the gush of dark red blood upon ambulation is typical due to the pooling of blood in the vagina when lying down, which is then released upon standing. The firm, midline uterus at the level of the umbilicus indicates normal involution of the uterus postpartum. Therefore, this scenario is consistent with the expected postpartum physiological changes rather than complications like hematoma, lacerations, or abnormal excessive bleeding. Choices A, B, and D are incorrect because the described findings are more indicative of normal postpartum processes rather than complications such as vaginal hematoma, lacerations, or excessive bleeding.

4. A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

• A. Palpate the fundus to identify the fetal part.
• B. Determine the location of the fetal back.
• C. Palpate for the fetal part presenting at the inlet.
• D. All of the Above

Correct answer: D

Rationale: The correct sequence for the nurse to follow when performing Leopold maneuvers is as follows: first, palpate the client's fundus to identify the fetal part, second, determine the location of the fetal back, third, palpate for the fetal part presenting at the inlet, and finally, palpate the cephalic prominence to identify the attitude of the head. Therefore, option D, 'All of the Above,' is the correct answer as it includes all the steps in the correct sequence. Choices A, B, and C are incorrect as they do not represent the complete sequence required for performing Leopold maneuvers.

5. When caring for clients in a prenatal clinic, a nurse should report which client's weight gain to the provider?

• A. 1.8 kg (4 lb) weight gain in the first trimester
• B. 3.6 kg (8 lb) weight gain in the first trimester
• C. 6.8 kg (15 lb) weight gain in the second trimester
• D. 11.3 kg (25 lb) weight gain in the third trimester

Correct answer: B

Rationale: A weight gain of 3.6 kg (8 lb) in the first trimester is excessive and should be reported to the provider for further evaluation. Excessive weight gain in the first trimester can be a sign of potential issues that need monitoring and intervention to ensure the well-being of both the mother and the baby. Choices A, C, and D represent weight gains that are within normal ranges for the respective trimesters and do not raise immediate concerns for reporting to the provider.

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