Nursing Elites

1. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

• A. Administer oxygen by mouth at 2L/min
• B. Gradually warm the infant under a radiant heat source
• C. Notify the pediatrician of the infant's vital signs
• D. Perform a heel-stick to maintain blood glucose levels

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.

2. A client with preeclampsia is receiving magnesium sulfate by continuous IV infusion. Which finding should the nurse report to the provider?

• A. Blood pressure 148/94 mm Hg
• B. Respiratory rate 14/min
• C. Urinary output 20 mL/hr
• D. 2+ deep tendon reflexes

Correct answer: C

Rationale: In a client with preeclampsia receiving magnesium sulfate, a urinary output of 20 mL/hr is a concerning finding as it may indicate renal impairment or magnesium toxicity. Adequate urinary output is crucial for eliminating excess magnesium and preventing toxicity. The nurse should report this finding to the provider for further evaluation. A blood pressure of 148/94 mm Hg is elevated but expected in a client with preeclampsia. A respiratory rate of 14/min is within the normal range. 2+ deep tendon reflexes are a common finding in clients receiving magnesium sulfate and are not a cause for concern unless they progress to hyperreflexia or clonus.

3. _____ is a life-threatening disease, characterized by high blood pressure that may afflict women late in the second or early in the third trimester.

• A. Rubella
• B. Syphilis
• C. Preeclampsia
• D. Phenylketonuria

Correct answer: C

Rationale: Preeclampsia is a serious pregnancy complication characterized by high blood pressure that typically occurs in the second half of pregnancy. If left untreated, it can lead to severe complications for both the mother and the baby. Rubella (choice A) is a viral infection that can harm the developing fetus but is not directly related to high blood pressure in pregnancy. Syphilis (choice B) is a sexually transmitted infection that can affect pregnancy but does not specifically cause high blood pressure. Phenylketonuria (choice D) is a genetic disorder that affects metabolism and is not associated with high blood pressure in pregnancy.

4. Following an amniocentesis, a nurse is caring for a client. The nurse should observe the client for which of the following complications?

• A. Hyperemesis
• B. Proteinuria
• C. Hypoxia
• D. Hemorrhage

Correct answer: D

Rationale: After an amniocentesis, the nurse should monitor the client for potential complications, with hemorrhage being a significant concern due to the invasive nature of the procedure. Hyperemesis (severe vomiting), proteinuria (excessive protein in the urine), and hypoxia (low oxygen levels) are not typically associated with amniocentesis and are less likely to occur compared to hemorrhage, which is a more common complication that requires prompt recognition and intervention.

5. A client at 26 weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

• A. Reassure the client that the AFP results are likely to be a false reading.
• B. Explain that a sonogram should be scheduled for definitive results.
• C. Inform her that a repeat alpha-fetoprotein (AFP) test should be evaluated.
• D. Discuss options for intrauterine surgical correction of congenital defects.

Correct answer: B

Rationale: An elevated AFP level during pregnancy can indicate potential fetal anomalies. Further evaluation is necessary to confirm the findings and assess the need for additional interventions. Scheduling a sonogram is the appropriate next step as it can provide more definitive results and help identify any underlying issues. Choice A is incorrect because dismissing the elevated AFP level as a false reading without further investigation can lead to missing important information about the baby's health. Choice C is not the best immediate action, as scheduling a sonogram would provide more detailed information than just repeating the AFP test. Choice D is incorrect as discussing intrauterine surgical correction is premature at this stage and not typically indicated based solely on an elevated AFP level.

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