Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Determine fetal position by performing Leopold maneuvers.
Determine fetal position by performing Leopold maneuvers:Leopold maneuvers are used to determine the fetal position and presentation by palpating the mother's abdomen. While this information can be valuable, it's not the highest priority in a situation where there is significant vaginal bleeding.
B. Assess the fetal heart rate and client's contraction pattern
Assess the fetal heart rate and client's contraction pattern:This is the highest priority because it directly addresses the immediate concern. Monitoring the fetal heart rate and contraction pattern helps to assess the well-being of both the mother and the baby.
C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration
Confirm Rh and Coombs status for Rho(D) immunoglobulin administration: While determining Rh status is important, it may not be the immediate priority in this situation. However, if there is a need for Rho(D) immunoglobulin administration, it should be addressed in a timely manner.
D. Perform sterile vaginal examination to determine dilatation
Perform sterile vaginal examination to determine dilatation:Performing a sterile vaginal examination is an important aspect of assessing the progress of labor, but it may not be the highest priority when there is significant vaginal bleeding. The focus initially should be on assessing the fetal heart rate and contraction pattern.
This question is an excerpt from Nurse Dive's nursing test bank - Samuel Merrit University Oaklands Hesi Maternity (Labor and Delivery) Proctored Exam. Take the full exam now
Full Explanation
A. Determine fetal position by performing Leopold maneuvers:
Leopold maneuvers are used to determine the fetal position and presentation by palpating the mother's abdomen. While this information can be valuable, it's not the highest priority in a situation where there is significant vaginal bleeding.
B. Assess the fetal heart rate and client's contraction pattern:
This is the highest priority because it directly addresses the immediate concern. Monitoring the fetal heart rate and contraction pattern helps to assess the well-being of both the mother and the baby.
C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration:
While determining Rh status is important, it may not be the immediate priority in this situation. However, if there is a need for Rho(D) immunoglobulin administration, it should be addressed in a timely manner.
D. Perform sterile vaginal examination to determine dilatation:
Performing a sterile vaginal examination is an important aspect of assessing the progress of labor, but it may not be the highest priority when there is significant vaginal bleeding. The focus initially should be on assessing the fetal heart rate and contraction pattern.
Similar Questions
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
A. Hemoglobin and hematocrit
Hemoglobin and hematocrit:While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.
B. Abdominal contour and bowel sounds
Abdominal contour and bowel sounds:These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.
C. Heart rate and blood pressure
Heart rate and blood pressure: This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.
D. Urinary output and IV fluid intake
Urinary output and IV fluid intake:While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.
Full Explanation
A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.
B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.
C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.
D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
A. Flaring of the nares
Flaring of the nares:Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.
B. Shallow and irregular respirations
Shallow and irregular respirations:Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.
C. Respiratory rate of 50 breaths per minute
Respiratory rate of 50 breaths per minute: While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.
D. Abdominal breathing with synchronous chest movement
Abdominal breathing with synchronous chest movement:Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.
Full Explanation
A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.
B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.
C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.
D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
A. Unilateral lower leg pain.
Unilateral lower leg pain:Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus
Soft, spongy fundus:A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour.
Saturating two perineal pads per hour: Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute
Pulse rate of 56 beats/minute:A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.
Full Explanation
A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.