Nursing Elites

1. A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?

• A. Gravidity and parity.
• B. Time and amount of last oral intake.
• C. Date of last normal menstrual period.
• D. Frequency and intensity of contractions.

Correct answer: C

Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus. Choices A, B, and D are important in labor assessment, but in this scenario, the most crucial information needed is the date of the last normal menstrual period to estimate the gestational age.

2. 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.

3. Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse take next?

• A. Initiate positive pressure ventilation.
• B. Intervene after the one-minute Apgar assessment.
• C. Initiate CPR on the infant.
• D. Assess the infant's blood glucose level.

Correct answer: A

Rationale: A heart rate below 100 bpm in a newborn indicates bradycardia and requires intervention. Positive pressure ventilation should be initiated to improve oxygenation and help increase the infant's heart rate. This intervention is crucial to support the newborn's transition to extrauterine life and prevent further complications.

4. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?

• A. Which symptom did you experience first?
• B. Are you consuming large amounts of salty foods?
• C. Have you traveled to a foreign country recently?
• D. Do you have a history of rheumatic fever?

Correct answer: D

Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.

5. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

• A. Weight gain.
• B. Reduction of fever.
• C. Improved caloric intake.
• D. Reduction of edema.

Correct answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

Similar Questions