Nursing Elites

1. When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs and symptoms of cardiac decompensation. Which critical findings would the nurse find on assessment of the client experiencing this condition?

• A. Regular heart rate and hypertension.
• B. Increased urinary output, tachycardia, and dry cough.
• C. Shortness of breath, bradycardia, and hypertension.
• D. Dyspnea, crackles, and an irregular, weak pulse.

Correct answer: D

Rationale: In pregnant women with cardiac problems, signs of cardiac decompensation include dyspnea, crackles, an irregular, weak, and rapid pulse, rapid respirations, a moist and frequent cough, generalized edema, increasing fatigue, and cyanosis of the lips and nailbeds. Choice A is incorrect as a regular heart rate and hypertension are not typically associated with cardiac decompensation. Choice B is incorrect as increased urinary output and dry cough are not indicative of cardiac decompensation, only tachycardia is. Choice C is incorrect as bradycardia and hypertension are not typically seen in cardiac decompensation; dyspnea is a critical sign instead.

2. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?

• A. Dilation of the cervix.
• B. Descent of the fetus to –2 station.
• C. Rupture of the amniotic membranes.
• D. Increase in bloody show.

Correct answer: A

Rationale: During the first stage of labor, effective uterine contractions lead to cervical dilation. Dilation of the cervix is a key indicator that uterine contractions are progressing labor. Descent of the fetus to -2 station (Choice B) is related to the fetal position in the pelvis and not a direct indicator of uterine contraction effectiveness. Rupture of the amniotic membranes (Choice C) signifies the rupture of the fluid-filled sac surrounding the fetus and does not directly reflect uterine contraction effectiveness. An increase in bloody show (Choice D) can be a sign of impending labor, but it is not a direct indicator of uterine contraction effectiveness.

3. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

• A. Assess the blood pressure for hypertension.
• B. Gently massage fundus every four hours.
• C. Observe for signs of uterine hemorrhage.
• D. Encourage direct contact with the infant.

Correct answer: C

Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.

4. Which of the following statements is a characteristic of supermales?

• A. They are somewhat taller than average.
• B. Their facial hair growth is minimal when compared to normal males.
• C. They suffer from gynecomastia.
• D. They are typically impotent.

Correct answer: A

Rationale: The correct characteristic of supermales, individuals with an XYY chromosome pattern, is that they are somewhat taller than average. Choice B is incorrect as supermales do not exhibit minimal facial hair growth compared to normal males. Choice C is incorrect as gynecomastia, the development of male breasts, is not a characteristic of supermales. Choice D is also incorrect as impotence is not a typical characteristic associated with supermales.

5. A client at 38 weeks of gestation has a prescription for intravaginal misoprostol. Which of the following statements should the nurse make?

• A. “You will need to stay in a side-lying position for 30 minutes after each dose.”
• B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.”
• C. “You will receive a magnesium supplement immediately following therapy.”
• D. “You will need to have a full bladder before the therapy begins.”

Correct answer: A

Rationale: The correct answer is A. Instructing the client to stay in a side-lying position after receiving misoprostol intravaginally is essential. This position helps keep the medication in place, allowing for better absorption. Choice B is incorrect because oxytocin administration is not typically indicated after misoprostol use. Choice C is incorrect as magnesium supplementation is not part of the standard protocol for misoprostol administration. Choice D is incorrect as having a full bladder is not necessary before initiating misoprostol therapy.

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