Nursing Elites

1. When a client delivers a viable infant but experiences excessive uncontrolled vaginal bleeding after the IV Pitocin infusion, what information is most important for the nurse to provide when notifying the healthcare provider?

• A. Maternal blood pressure
• B. Estimated blood loss
• C. Length of labor
• D. Amount of IV fluids administered

Correct answer: A

Rationale: In a situation where a client is experiencing excessive uncontrolled vaginal bleeding post-delivery, the most crucial information for the nurse to provide the healthcare provider is the maternal blood pressure. Maternal blood pressure can help assess the severity of the bleeding and guide immediate interventions to stabilize the client's condition. Estimated blood loss, length of labor, and amount of IV fluids administered are important pieces of information but in this scenario, maternal blood pressure takes precedence as it directly indicates the client's current hemodynamic status.

2. The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?

• A. Inspect the perineal pad.
• B. Encourage voiding.
• C. Monitor vital signs.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: A boggy uterus that is displaced above and to the right of the umbilicus may indicate a full bladder, which can impede uterine contraction and lead to hemorrhage. Encouraging the client to void helps relieve pressure on the uterus, promoting better contraction and preventing postpartum hemorrhage.

3. 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.

4. A newborn with a yellow abdomen and chest is being assessed. What should be the nurse's initial action?

• A. Assess bilirubin level.
• B. Administer phototherapy.
• C. Encourage feeding to help reduce bilirubin levels.
• D. Perform a bilirubin test every hour.

Correct answer: A

Rationale: The correct action when assessing a newborn with a yellow abdomen and chest is to initially assess the bilirubin level. This helps determine the severity of jaundice in the newborn. Administering phototherapy (choice B) is a treatment intervention that follows the assessment. Encouraging feeding (choice C) can help with bilirubin excretion but is not the initial assessment. Performing a bilirubin test every hour (choice D) may not be necessary initially and could lead to unnecessary interventions.

5. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?

• A. Obtain a culture of any sputum or wound drainage
• B. Initiate normal saline IV at 50 ml/hr
• C. Administer a loading dose of penicillin IM
• D. Administer the initial dose of folic acid PO

Correct answer: B

Rationale: In a child with a sickle cell crisis, the priority intervention is to initiate normal saline IV at 50 ml/hr to manage dehydration and help alleviate pain. This intervention helps improve hydration status and supports the circulation of sickled red blood cells, reducing the risk of vaso-occlusive episodes and associated pain. Obtaining a culture of any sputum or wound drainage (Choice A) may be necessary but is not the initial priority. Administering a loading dose of penicillin IM (Choice C) is important but not the first intervention. Administering the initial dose of folic acid PO (Choice D) is beneficial but does not address the immediate need for hydration in a sickle cell crisis.

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