Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What action should the nurse take first?
A. Call the healthcare provider.
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
B. Encourage the client to void.
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
C. Administer ibuprofen 800 mg by mouth.
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
D. Increase the intravenous fluid to 150 mL/hour.
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.
This question is an excerpt from Nurse Dive's nursing test bank - Care Hope College RN HESI Maternity Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
Choice B rationale
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Choice C rationale
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
Choice D rationale
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.
Similar Questions
At 20-weeks gestation, a client who has gained 20 pounds (9.1 kg) during this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the client’s only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?
A. Leakage from breasts.
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
B. Gestational weight gain.
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
C. Presence of fetal movement.
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
D. Fundal height measurement.
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
Full Explanation
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping.
She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor.
Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
A. Assess the fetal heart rate and client’s contraction pattern.
Bright red bleeding in the third trimester of a pregnancy with an Rh-negative mother is an obstetric emergency and warrants the highest priority. The immediate assessment of the fetal heart rate (FHR) and the mother's contraction pattern is crucial. The nurse must determine if the bleeding is caused by conditions such as placental abruption or placenta previa, both of which are life-threatening for the mother and the fetus.
B. Perform sterile vaginal examination to determine dilatation.
While a sterile vaginal examination may eventually be necessary to diagnose the cause of bleeding, it is not the immediate priority. Assessment of fetal well-being and maternal status takes precedence. Additionally, performing a vaginal examination increases the risk of further hemorrhage and potential infection.
C. Determine fetal position by performing Leopold maneuvers.
Leopold maneuvers are used to determine fetal presentation and position, but they are not the priority intervention in this scenario. The nurse's main concern is stabilizing the mother and assessing for signs of fetal distress.
D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.
Assessing the woman's Rh and Coombs status for RhoGam administration is important. Still, it is not the most immediate priority in this life-threatening situation. The priority is to assess fetal well-being and stabilize the mother. If placental abruption is suspected, RhoGam administration may not be indicated.
Full Explanation
Choice A rationale
Bright red bleeding in the third trimester of a pregnancy with an Rh-negative mother is an obstetric emergency and warrants the highest priority. The immediate assessment of the fetal heart rate (FHR) and the mother's contraction pattern is crucial. The nurse must determine if the bleeding is caused by conditions such as placental abruption or placenta previa, both of which are life-threatening for the mother and the fetus.
Choice B rationale
While a sterile vaginal examination may eventually be necessary to diagnose the cause of bleeding, it is not the immediate priority. Assessment of fetal well-being and maternal status takes precedence. Additionally, performing a vaginal examination increases the risk of further hemorrhage and potential infection.
Choice C rationale
Leopold maneuvers are used to determine fetal presentation and position, but they are not the priority intervention in this scenario. The nurse's main concern is stabilizing the mother and assessing for signs of fetal distress.
Choice D rationale
Assessing the woman's Rh and Coombs status for RhoGam administration is important. Still, it is not the most immediate priority in this life-threatening situation. The priority is to assess fetal well-being and stabilize the mother. If placental abruption is suspected, RhoGam administration may not be indicated.
One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?
A. Assess the client’s perineal area for signs of a perineal hematoma.
While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.
B. Assess the client’s temperature, pulse, and respirations every 4 hours.
Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.
C. Notify the healthcare provider, since this finding is indicative of infection.
While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.
D. Check the differential, since the WBC is normal for this client.
A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.
Full Explanation
Choice A rationale
While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.
Choice B rationale
Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.
Choice C rationale
While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.
Choice D rationale
A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.