Nursing Elites

1. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?

• A. Insert a straight urinary catheter to drain the bladder.
• B. Scan the bladder for urinary retention.
• C. Palpate the suprapubic area for fetal head position.
• D. Test the fluid with a nitrazine strip.

Correct answer: D

Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.

2. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

• A. 3+ deep tendon reflexes and hyperreflexia.
• B. Periorbital edema, flashing lights, and aura.
• C. Epigastric pain in the third trimester.
• D. Recent decreased urinary output.

Correct answer: A

Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.

3. After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

• A. Check the differential, as the WBC count can be normal for this client.
• B. Assess the client's temperature, pulse, and respirations every 4 hours.
• C. Notify the healthcare provider, as this finding may indicate infection.
• D. Assess the client's perineal area for signs of a perineal hematoma.

Correct answer: A

Rationale: In postpartum clients, a white blood cell count of 15,000/mm3 can be within normal limits due to physiological changes that occur after childbirth. Checking the differential count would provide a more detailed analysis of the specific types of white blood cells present, helping to differentiate between normal postpartum changes and potential infection. This action allows the nurse to gather more information before escalating the situation to the healthcare provider or initiating other assessments. Assessing vital signs and the perineal area are important aspects of postpartum care but may not be the priority in this scenario where the white blood cell count can be influenced by normal physiological changes.

4. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?

• A. Apply cold compresses to both breasts for comfort.
• B. Instruct the client to run warm water on her breasts.
• C. Wear a loose-fitting bra to prevent nipple irritation.
• D. Express small amounts of milk to relieve pressure.

Correct answer: A

Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.

5. At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?

• A. Color and consistency of fluid.
• B. Estimated amount of fluid.
• C. Any odor noted at the rupture of membranes.
• D. Time of membrane rupture.

Correct answer: A

Rationale: Assessing the color and consistency of amniotic fluid is crucial as it can indicate the presence of meconium, which suggests potential fetal distress. This information guides the need for further assessments and interventions to ensure the well-being of the mother and fetus. Estimating the amount of fluid is not as critical as determining the color and consistency to identify fetal distress. While noting any odor is important, it is secondary to assessing the fluid itself. Knowing the time of membrane rupture is helpful but not as crucial as evaluating the characteristics of the amniotic fluid.

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