Nursing Elites

1. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?

• A. Notify the healthcare provider of the finding.
• B. Document the findings.
• C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
• D. Wait 15 minutes and then recheck the FHR.

Correct answer: B

Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.

2. The LPN is caring for a client newly diagnosed with HIV. Which statement made by the client regarding antiretroviral therapy (ART) would require correction from the nurse?

• A. "If I start ART and use condoms, I'm less likely to transmit HIV to my partner."?
• B. "I can still use ART even though I am Hepatitis C positive."?
• C. "I will need to be on ART indefinitely."?
• D. "I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3."?

Correct answer: D

Rationale: The correct answer is the statement, "I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3."? This statement would require correction from the nurse because initiating ART when the CD4 count is over 1,000 cells/mm3 is not supported by guidelines. The World Health Organization (WHO) recommends making treatment a priority for those with a CD4 count of ?350 cells/mm3, as early intervention can help delay disease progression. Therefore, waiting for a CD4 count of over 1,000 cells/mm3 is not in line with current recommendations. Choice A is correct, as studies have shown that using condoms along with ART can significantly reduce the risk of HIV transmission to sexual partners. Choice B is also correct because being Hepatitis C positive does not contraindicate the use of ART. Choice C is correct as well, as ART is typically needed indefinitely to maintain viral suppression and manage HIV. Therefore, the only statement that would require correction is Choice D.

3. A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?

• A. ''I will call my nurse-midwife if I experience any redness, swelling, or tenderness in my legs.''
• B. ''My temperature needs to remain within a normal range.''
• C. ''Frequent urination and burning when I urinate are expected.''
• D. ''Feelings of pelvic fullness or pelvic pressure are a sign of a problem.''

Correct answer: C

Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.

4. The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?

• A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
• B. The client states they will remain in the Semi-Fowler's position for 30 minutes following the administration of the medications.
• C. The client mixes each medication separately in warm water.
• D. The client mixes their medications with their tube-feeding formula.

Correct answer: D

Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.

5. A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

• A. If your 2-year-old becomes angry or jealous, you should consider preparing the child for the new sibling rather than seeking psychological intervention.
• B. Don't worry; every 2-year-old may need time to adjust to a newborn sibling.
• C. Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.
• D. A 2-year-old toddler focuses on exploring the environment, but it's important to prepare the child for the new sibling.

Correct answer: C

Rationale: The correct response by the nurse is, 'Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.' Toddlers are generally unaware of the changes during pregnancy and may not understand the impending arrival of a new sibling. It is essential to prepare the child gradually for the new baby's arrival by making any necessary changes in sleeping arrangements beforehand. Expecting a young child to immediately welcome a new sibling without prior preparation is unrealistic. Option A is incorrect as suggesting psychological intervention prematurely is not appropriate. Option B is incorrect as assuming all 2-year-olds would immediately welcome a newborn is unrealistic. Option D is incorrect as dismissing the concerns without addressing the need for preparation is not appropriate in this situation.

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