Nursing Elites

1. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?

• A. Auscultate the lungs for respiratory pneumonia.
• B. Change to latex-free gloves when handling infant.
• C. Draw blood to analyze for streptococcal infection.
• D. Apply zinc oxide to perineum with each diaper change.

Correct answer: B

Rationale: Latex allergy is a concern in patients with myelomeningocele, so switching to latex-free gloves is important.

2. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

• A. Obtain blood culture.
• B. Administer penicillin.
• C. Cover lesion with a dressing.
• D. Prepare her for cesarean section.

Correct answer: D

Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.

3. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?

• A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
• B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
• C. I know you're upset. Would you like to talk about some activities you could do while in bed?
• D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.

Correct answer: A

Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.

4. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

• A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
• B. The chorea or movements are temporary and will eventually disappear.
• C. Permanent lifestyle changes are not needed to promote safety in the home.
• D. Consistent discipline is not directly related to controlling the movements.

Correct answer: B

Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.

5. Upon admission to the prenatal clinic, a 23-year-old woman informs the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What is this client's expected date of delivery (EDD)?

• A. November 22.
• B. November 8.
• C. December 22.
• D. October 22.

Correct answer: A

Rationale: To determine the expected date of delivery (EDD) using Nägele's rule, add 7 days to the first day of the last menstrual period (LMP) which is February 15, resulting in February 22. Then, subtract 3 months from February 22, which gives November 22 as the estimated due date.

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