Nursing Elites

1. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7-pound, 10-ounce (3220-gram) infant. Which information should the nurse provide to the client about these findings?

• A. The uterus should be firm to prevent an intrauterine infection.
• B. Both the lower uterine segment and the fundus must be massaged.
• C. A firm uterus prevents the endometrial lining from being sloughed.
• D. Clots may form inside a boggy uterus and need to be expelled.

Correct answer: D

Rationale: After childbirth, a boggy uterus indicates poor uterine tone, which can lead to the formation of clots. Massaging the fundus helps the uterus contract and expel clots, reducing the risk of postpartum hemorrhage. Choices A, B, and C are incorrect because the main concern with a boggy uterus is the risk of clot formation and postpartum hemorrhage, not solely preventing intrauterine infection, massaging the lower uterine segment, or preventing the endometrial lining from sloughing.

2. Daisy was always unusually short for her age. She was unable to conceive a child after marriage, and upon visiting a doctor, she was prescribed estrogen replacement therapy. Daisy is most likely suffering from:

• A. Phenylketonuria (PKU).
• B. Cystic fibrosis.
• C. Turner syndrome.
• D. Huntington’s disease (HD).

Correct answer: C

Rationale: Daisy's symptoms of short stature and infertility, along with the prescription of estrogen replacement therapy, are indicative of Turner syndrome. Turner syndrome is a genetic condition in which a female is partially or completely missing one X chromosome. This results in short stature, infertility, and other physical characteristics. Phenylketonuria (PKU) is a metabolic disorder caused by a mutation in the gene responsible for the breakdown of the amino acid phenylalanine. Cystic fibrosis is a genetic disorder affecting the respiratory and digestive systems. Huntington's disease (HD) is a neurodegenerative disorder that affects muscle coordination and leads to cognitive decline.

3. A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?

• A. Membranes are intact.
• B. 2+ pitting edema in lower extremities.
• C. Contractions decrease with walking.
• D. Cervical dilation is 1 centimeter.

Correct answer: C

Rationale: The correct answer is C. Contractions that decrease with walking are typically indicative of false labor, as true labor contractions tend to intensify with activity. Choices A, B, and D are incorrect. A) Intact membranes are a normal finding and do not confirm the absence of labor. B) 2+ pitting edema in lower extremities is a sign of fluid retention and not directly related to labor status. D) Cervical dilation of 1 centimeter indicates some cervical changes, but it alone does not confirm active labor.

4. 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.

5. What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

• A. Assessing the strength of uterine contractions
• B. Re-evaluating the need for medication
• C. Reminding her to push 3 times with each contraction
• D. Assisting her to maintain control

Correct answer: D

Rationale: During the transitional phase of labor, which is the most intense phase, the primary focus of nursing care for a client who anticipates an unmedicated delivery should be assisting her to maintain control. This is essential to help her manage the intense pain and anxiety associated with this phase without the use of medication. Assessing the strength of uterine contractions (Choice A) is important but not the primary focus during the transitional phase. Re-evaluating the need for medication (Choice B) is not applicable as the client anticipates an unmedicated delivery. Reminding her to push 3 times with each contraction (Choice C) is more related to the pushing stage of labor and not the transitional phase.

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