Nursing Elites

1. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?

• A. Alert the neonatal team and prepare for neonatal resuscitation
• B. Notify the healthcare provider from the client’s bedside
• C. Obtain written consent for an emergency cesarean section
• D. Draw a blood sample for stat hemoglobin and hematocrit

Correct answer: B

Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.

2. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the client's nursing care plan?

• A. Assess temperature every hour.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations every 4 hours.
• D. Keep an airway at the bedside.

Correct answer: D

Rationale: In the case of eclampsia, the priority intervention is to keep an airway at the bedside. Eclampsia is associated with a high risk of convulsions, and having an airway readily available is crucial for prompt intervention in the event of seizures. Assessing temperature, allowing family visitation, and monitoring vital signs are important aspects of care but ensuring airway patency takes precedence in this situation to manage potential complications and ensure the client's safety.

3. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?

• A. Measure the infant’s head-to-heel length
• B. Observe the infant for sunsetting eyes
• C. Palpate the anterior fontanel for tension and bulging
• D. Plot the measurement on the infant’s growth chart

Correct answer: C

Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.

4. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

• A. Suction the oral and nasal passages.
• B. Give oxygen by positive pressure.
• C. Stimulate the infant to cry.
• D. Turn the infant onto the right side.

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

5. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

Similar Questions