Nursing Elites

1. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?

• A. Decrease the oxytocin infusion rate
• B. Determine current cervical dilation
• C. Request placement of the epidural
• D. Give a bolus of intravenous fluids

Correct answer: D

Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.

2. A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention?

• A. Ask the client’s mother to call an ambulance for transport to the hospital immediately.
• B. Determine what physical activities the client has performed for the past 24 hours.
• C. Teach the client how to perform pelvic rock exercises and observe for correct feedback.
• D. Ask the client if she has experienced any recent changes in vaginal discharge.

Correct answer: D

Rationale: The priority nursing intervention in this situation is to ask the client if she has experienced any recent changes in vaginal discharge. Changes in vaginal discharge can indicate preterm labor, making it crucial to assess promptly. This information will help determine if the client needs immediate medical attention and appropriate interventions to prevent preterm birth and ensure the well-being of the mother and the baby. Option A is not the priority as back pain alone does not warrant immediate ambulance transport. Option B is less relevant in this context as the focus should be on immediate concerns related to pregnancy. Option C is not the priority as addressing back pain should come after ruling out urgent pregnancy-related issues.

3. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Unilateral lower leg pain.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 bpm.
• D. Soft, spongy fundus.

Correct answer: C

Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.

4. During a prenatal visit, the LPN/LVN discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have

• A. lower Apgar scores.
• B. lower birth weights.
• C. respiratory distress.
• D. a higher rate of congenital anomalies.

Correct answer: B

Rationale: When mothers smoke during pregnancy, it is associated with intrauterine growth restriction, which leads to lower birth weights in infants. Maternal smoking can restrict the flow of oxygen and nutrients to the fetus, affecting its growth and development. This can result in babies being born with lower birth weights, which can have various health implications for the newborn. Choices A, C, and D are incorrect as smoking during pregnancy is primarily linked to intrauterine growth restriction and lower birth weights in infants, rather than lower Apgar scores, respiratory distress, or a higher rate of congenital anomalies.

5. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

• A. 3+ deep tendon reflexes and hyperreflexia.
• B. Periorbital edema, flashing lights, and aura.
• C. Epigastric pain in the third trimester.
• D. Recent decreased urinary output.

Correct answer: A

Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.

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