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. A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?

• A. Notifying the healthcare provider
• B. Stopping the oxytocin infusion
• C. Checking the woman's blood pressure and pulse
• D. Increasing the intravenous (IV) rate of the nonadditive solution

Correct answer: B

Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.

3. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

• A. administering immune globulin intravenously
• B. assessing the extremities for edema, redness, and desquamation every 8 hours
• C. explaining progression of the disease to the client and their family
• D. assessing heart sounds and rhythm

Correct answer: C

Rationale: Educating the client and their family about the progression of Kawasaki disease is crucial for promoting a positive body image. By explaining when symptoms are expected to improve and resolve, the client and family can better understand that there will be no permanent disruption in physical appearance that could negatively impact body image. Administering immune globulin intravenously is a treatment for Kawasaki disease but does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly address body image concerns. Assessing heart sounds and rhythm is essential for evaluating cardiac effects of Kawasaki disease but is not the most direct measure for promoting a positive body image.

4. A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?

• A. Begin in the right lower quadrant.
• B. Use the bell end of the stethoscope.
• C. Hold the stethoscope lightly against the skin.
• D. Listen for at least 5 minutes before deciding that bowel sounds are absent.

Correct answer: A

Rationale: To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment. Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds. Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation. Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.

5. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?

• A. Insert a gloved finger into the mother's vagina to feel for cord compression
• B. Position the mother so that her hips are elevated
• C. Notify the registered nurse
• D. Perform a vaginal examination on the mother

Correct answer: B

Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.

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