Nursing Elites

1. Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?

• A. At the level of the umbilicus
• B. Two centimeters above the umbilicus
• C. Midway between the symphysis pubis and umbilicus
• D. In the pelvic cavity

Correct answer: C

Rationale: The correct answer is midway between the symphysis pubis and the umbilicus. Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus can be palpated at this location but then rises to a level just above the umbilicus before sinking to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus starts descending gradually. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Choices A and B are incorrect as the fundus is not initially at the level of the umbilicus or 2 centimeters above it. Choice D is also incorrect as the fundus does not remain in the pelvic cavity immediately after delivery.

2. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

• A. Firm pressure
• B. Pain behind the eyes
• C. Pain during palpation
• D. Pressure producing an acute headache

Correct answer: A

Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.

3. When performing an abdominal assessment, what is the correct order of the tasks?

• A. inspect, percuss, palpate, auscultate
• B. inspect, palpate, percuss, auscultate
• C. inspect, auscultate, percuss, palpate
• D. inspect, palpate, auscultate, percuss

Correct answer: C

Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.

4. Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?

• A. Liver
• B. Spleen
• C. Pancreas
• D. Appendix

Correct answer: D

Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.

5. When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?

• A. Is more advanced than expected
• B. Is developing as expected
• C. Is slower than expected
• D. Will require assistance from a speech therapist

Correct answer: C

Rationale: When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.

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