Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
A. Palpate the client's uterine fundus.
Palpating the client's uterine fundus is an essential nursing intervention after childbirth to assess for uterine atony or excessive bleeding. However, in this scenario, the client has already saturated two perineal pads with blood in a short period, indicating active bleeding. Therefore, the priority is to take immediate action to stop the bleeding, rather than assessing the uterine fundus.
B. Assist the client on a bedpan to urinate.
Assisting the client on a bedpan to urinate is important for postpartum care and can help prevent bladder distension and discomfort. However, it is not the priority in this situation where the client is experiencing significant postpartum bleeding. Managing the bleeding is the primary concern at this time.
C. Prepare to administer oxytocic medication.
The correct priority nursing intervention is to prepare to administer oxytocic medication. Oxytocic drugs, such as oxytocin (Pitocin), are used to stimulate uterine contractions and prevent or treat postpartum hemorrhage. Administering this medication promptly can help control the bleeding and prevent further complications.
D. Increase the client's fluid intake.
Increasing the client's fluid intake may be beneficial for postpartum hydration, especially if the client has lost a significant amount of blood. However, it is not the priority in this situation. Managing the postpartum bleeding takes precedence, and if intravenous fluids are needed, they can be given concurrently with the administration of oxytocic medication.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
A. Palpating the client's uterine fundus is the priority intervention because excessive postpartum bleeding could indicate uterine atony, where the uterus fails to contract effectively. Assessing the fundus will help determine if it is boggy and if fundal massage is needed to promote uterine contraction and reduce bleeding.
B. Assisting the client to urinate is an important intervention if the bladder is distended, as a full bladder can prevent the uterus from contracting properly. However, palpating the fundus to assess the source of bleeding takes priority over assisting with urination.
C. Preparing to administer oxytocic medication may be necessary if the uterine fundus is boggy and does not respond to massage, but the first step is to assess the fundus and attempt manual intervention before proceeding with medication.
D. Increasing the client's fluid intake can help maintain circulation and prevent dehydration, but it does not address the immediate concern of postpartum hemorrhage. Palpating the fundus is the priority action in this scenario
Similar Questions
A pregnant client's last menstrual period was May 4th, 2018. What is this client's estimated delivery date using Naegele's Rule?
A. February 11th, 2019.
Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.
B. February 27th, 2019.
This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.
C. April 27th, 2019.
This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.
D. August 11th, 2019.
This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.
Full Explanation
Choice A rationale:
Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.
Choice B rationale:
This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.
Choice C rationale:
This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.
Choice D rationale:
This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.
A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
A. "There is an increased risk of introducing infection.”
While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.
B. "This could initiate preterm labor.”
Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
C. "This could result in profound bleeding.”
The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.
D. "There is an increased risk of rupture of the membranes.”
While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Full Explanation
Choice A rationale:
While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.
Choice B rationale:
Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Choice C rationale:
The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.
Choice D rationale:
While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?
A. Monitor fluid intake.
Monitoring fluid intake is important for any newborn, but it is not the priority intervention for a small for gestational age (SGA) newborn. SGA infants are at risk of hypoglycemia due to limited glycogen stores, and monitoring blood glucose levels is crucial in identifying and managing hypoglycemia.
B. Monitor axillary temperature.
Monitoring axillary temperature is essential for all newborns to assess their thermoregulation. However, it is not the priority intervention for an SGA newborn. Hypoglycemia is a more immediate concern and must be addressed promptly.
C. Monitor blood glucose levels.
Monitoring blood glucose levels is the priority intervention for an SGA newborn. As mentioned earlier, SGA infants are at higher risk of hypoglycemia, which can lead to serious complications if not managed appropriately. By monitoring blood glucose levels, the nurse can detect and address hypoglycemia early.
D. Monitor weight.
Monitoring weight is important for tracking the growth and development of the newborn, but it is not the priority intervention in this scenario. The immediate concern for an SGA newborn is their blood glucose levels.
Full Explanation
Choice A rationale:
Monitoring fluid intake is important for any newborn, but it is not the priority intervention for a small for gestational age (SGA) newborn. SGA infants are at risk of hypoglycemia due to limited glycogen stores, and monitoring blood glucose levels is crucial in identifying and managing hypoglycemia.
Choice B rationale:
Monitoring axillary temperature is essential for all newborns to assess their thermoregulation. However, it is not the priority intervention for an SGA newborn. Hypoglycemia is a more immediate concern and must be addressed promptly.
Choice C rationale:
Monitoring blood glucose levels is the priority intervention for an SGA newborn. As mentioned earlier, SGA infants are at higher risk of hypoglycemia, which can lead to serious complications if not managed appropriately. By monitoring blood glucose levels, the nurse can detect and address hypoglycemia early.
Choice D rationale:
Monitoring weight is important for tracking the growth and development of the newborn, but it is not the priority intervention in this scenario. The immediate concern for an SGA newborn is their blood glucose levels.