Nursing Elites

1. When a client states, 'My water just broke,' what is the nurse's priority intervention?

• A. Perform Nitrazine testing.
• B. Assess the fluid.
• C. Check cervical dilation.
• D. Begin FHR monitoring.

Correct answer: D

Rationale: The correct answer is D: Begin FHR monitoring. The priority intervention when a client's water breaks is to assess the fetal well-being due to the risk of umbilical cord prolapse. Monitoring the fetal heart rate (FHR) will help the nurse ensure the fetus's well-being. Performing Nitrazine testing (choice A) or assessing the fluid (choice B) may provide information about the rupture of membranes but does not directly address fetal well-being. Checking cervical dilation (choice C) is important but not the priority when the client's water has broken.

2. During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?

• A. It is used to stimulate uterine contractions.
• B. It will decrease the incidence of uterine contractions.
• C. It lulls the fetus to sleep.
• D. It awakens a sleeping fetus.

Correct answer: D

Rationale: The acoustic vibration device is utilized during a nonstress test to awaken a sleeping fetus. This action helps ensure more accurate test results by eliciting fetal movements and heart rate accelerations, which are indicators of fetal well-being. Choices A, B, and C are incorrect because the primary purpose of the acoustic vibration device during a nonstress test is not to stimulate uterine contractions, decrease uterine contractions, or lull the fetus to sleep. Instead, it is specifically used to awaken a sleeping fetus to assess fetal well-being.

3. A client who is 3 days postpartum is receiving education on effective breastfeeding. Which of the following information should the nurse include?

• A. Your milk will replace colostrum in about 10 days.
• B. Your breasts should feel firm after breastfeeding.
• C. Your newborn should urinate at least 10 times per day.
• D. Your newborn should appear content after each feeding.

Correct answer: D

Rationale: The correct answer is D. The nurse should inform the client that a baby who is sated will appear content after feedings. This indicates that the baby is effectively emptying the breasts during feedings. Choices A, B, and C are incorrect because: A) Breast milk replaces colostrum within a few days, not 10 days. B) Breasts feeling firm after breastfeeding may indicate engorgement or plugged ducts, not necessarily effective breastfeeding. C) While the frequency of urination is important, it is not directly related to effective breastfeeding.

4. When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?

• A. 4
• B. 5
• C. 6
• D. 7

Correct answer: C

Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.

5. A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

• A. Respirations less than 12/min
• B. Urinary output less than 25 mL/hr
• C. Decreased level of consciousness
• D. All of the above

Correct answer: D

Rationale: Signs of magnesium sulfate toxicity include respirations less than 12/min, urinary output less than 25 mL/hr, and decreased level of consciousness. These signs indicate potential overdose of magnesium sulfate and require immediate attention to prevent further complications. Reporting these signs promptly is crucial to ensure the client's safety and well-being. Choice D, 'All of the above,' is the correct answer as all the listed findings are indicative of magnesium sulfate toxicity. Choices A, B, and C individually represent different signs of toxicity, making them incorrect on their own. Therefore, the nurse should be vigilant in identifying and reporting all these signs to prevent adverse outcomes.

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