Nursing Elites

1. A client at 37 weeks of gestation with severe gestational hypertension is being admitted by a nurse. Which of the following actions should the nurse NOT expect to implement?

• A. Administer magnesium sulfate IV.
• B. Provide a dark, quiet environment.
• C. Assess respiratory status every 4 hours.
• D. Ensure that calcium gluconate is readily available.

Correct answer: C

Rationale: Assessing respiratory status every 4 hours is not a priority for a client with severe gestational hypertension. In this scenario, the focus should be on monitoring blood pressure, assessing for signs of preeclampsia, administering medications like magnesium sulfate for seizure prophylaxis, and ensuring that calcium gluconate is readily available in case of magnesium toxicity. Respiratory status assessment is important in other conditions but is not directly related to managing severe gestational hypertension.

2. A client who experienced a cesarean birth due to dysfunctional labor expresses disappointment for not having a natural childbirth. Which response should the nurse make?

• A. Validate the client's feelings by saying, 'It sounds like you are feeling sad that things didn't go as planned.'
• B. Assure the client by stating, 'At least you know you have a healthy baby.'
• C. Encourage the client by suggesting, 'Maybe next time you can have a vaginal delivery.'
• D. Provide information by saying, 'You can resume sexual relations sooner than if you had delivered vaginally.'

Correct answer: A

Rationale: The correct response is to acknowledge and validate the client's feelings of disappointment. This empathetic approach demonstrates understanding and support for the client's emotional state, fostering a therapeutic nurse-client relationship. Options B, C, and D do not address the client's emotional needs or provide appropriate support in this situation.

3. A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

• A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions
• B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
• C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes
• D. A client who has a diagnosis of preeclampsia reports epigastric pain and an unresolved headache

Correct answer: D

Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.

4. A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

• A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
• B. Observe an area of redness on the breast of a client who is 1 day postpartum.
• C. Monitor vital signs during admission of a client who has gestational hypertension.
• D. Change the perineal pad of a client who just transferred from labor and delivery.

Correct answer: A

Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.

5. A client with preterm labor is being admitted. The nurse anticipates a prescription by the provider for which of the following medications?

• A. Prostaglandin E2
• B. Indomethacin
• C. Methylergonovine
• D. Oxytocin

Correct answer: B

Rationale: Indomethacin is used to delay premature labor by inhibiting uterine contractions. Prostaglandin E2, Methylergonovine, and Oxytocin are not typically used to manage preterm labor. Prostaglandin E2 can be used for cervical ripening and labor induction. Methylergonovine is used to prevent or control postpartum hemorrhage. Oxytocin is used for labor induction and augmentation of labor in term pregnancies.

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