In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?

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Question 1 of 5

In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?

Correct Answer: B

Rationale: Bright red trickle with a firm fundus suggests lacerations, not atony (soft fundus).

Question 2 of 5

An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: 'When can the tube can be used for feeding?' The nurse's best response would be which of these comments?

Correct Answer: C

Rationale: Initial drainage ensures patency and prevents aspiration before feeding begins.

Question 3 of 5

The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by

Correct Answer: C

Rationale: Hyperoxygenation prevents hypoxia during suctioning by pre-oxygenating the lungs.

Question 4 of 5

A 67 year-old client is admitted with substernal chest pain with that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). The priority nursing diagnosis for this client during the first 24 hours is

Correct Answer: C

Rationale: Impaired gas exchange due to reduced cardiac output is the primary concern post-MI.

Question 5 of 5

The nurse uses the DRG (Diagnosis Related Group) manual to

Correct Answer: C

Rationale: DRGs categorize diagnoses for hospital reimbursement purposes.

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