Nursing Elites

1. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

• A. A client with a urinary output of 300 ml in 8 hours
• B. A client reporting abdominal cramping during breastfeeding
• C. A client receiving magnesium sulfate with absent deep tendon reflexes
• D. A client reporting lochia rubra requiring changing perineal pads every 3 hours

Correct answer: C

Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.

2. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?

• A. Uterine atony.
• B. Uterine inversion.
• C. Vaginal hematoma.
• D. Vaginal laceration.

Correct answer: A

Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.

3. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

• A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
• B. Risk for altered gas exchange.
• C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
• D. Risk for increased cardiac output, related to the use of antihypertensive drugs.

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.

4. A healthcare professional is caring for a client who is 14 weeks of gestation. At which of the following locations should the healthcare professional place the Doppler device when assessing the fetal heart rate?

• A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
• B. Left Upper Abdomen
• C. Two fingerbreadths above the umbilicus
• D. Lateral at the Xiphoid Process

Correct answer: A

Rationale: At 14 weeks of gestation, the uterus is still relatively low in the abdomen. Placing the Doppler midline 2 to 3 cm above the symphysis pubis is appropriate for assessing the fetal heart rate. This location allows for better detection of the fetal heart tones as the uterus is at a lower position during this stage of pregnancy. Placing the Doppler on the left upper abdomen would not be ideal at 14 weeks gestation as the uterus is not yet at that level. Placing it two fingerbreadths above the umbilicus or lateral at the xiphoid process would also not be accurate for locating the fetal heart rate at this stage of gestation.

5. Does a blastocyst gain mass only when it receives nourishment from outside?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: A

Rationale: A blastocyst does indeed require external nourishment from the mother's body to continue developing and gaining mass. Without this external nourishment, the blastocyst would not be able to grow and develop properly. Therefore, the statement that a blastocyst gains mass only when it receives nourishment from outside is true. Choices B, C, and D are incorrect because they do not accurately reflect the dependency of a blastocyst on external nourishment for its development and growth.

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