Nursing Elites

1. 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.

2. When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?

• A. Hgb 12.2 g/dL
• B. Urine ketones present
• C. Alanine aminotransferase 20 IU/L
• D. Blood glucose 114 mg/dL

Correct answer: B

Rationale: The correct answer is B: Urine ketones present. The presence of urine ketones indicates dehydration, which is a common manifestation of hyperemesis gravidarum. Hyperemesis gravidarum is characterized by severe nausea, vomiting, weight loss, and electrolyte imbalances due to dehydration. Monitoring for ketonuria helps assess the degree of dehydration in clients with this condition. Choices A, C, and D are incorrect because hemoglobin level, alanine aminotransferase level, and blood glucose level are not specific manifestations of hyperemesis gravidarum. While these laboratory values may be abnormal in some cases, they are not typically used to diagnose or assess the condition.

3. During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?

• A. Apply palms of both hands to sides of the uterus
• B. Palpate the fundus of the uterus
• C. Grasp the lower uterine segment between thumb and fingers
• D. Stand facing the client's feet with fingertips outlining cephalic prominence

Correct answer: B

Rationale: Palpating the fundus of the uterus during Leopold maneuvers is crucial to identify the fetal lie. This technique allows the nurse to determine the position of the baby's back and locate the fetal heart sounds, aiding in assessing the fetal lie. Choices A, C, and D are incorrect as they do not directly relate to identifying the fetal lie during Leopold maneuvers. Applying palms to the sides of the uterus or grasping the lower uterine segment do not provide the necessary information about the fetal lie. Standing facing the client's feet and outlining cephalic prominence is more related to assessing the fetal presentation, not the fetal lie.

4. While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

• A. Place the client in the Trendelenburg position
• B. Apply finger pressure to the presenting part
• C. Administer oxygen at 10 L/min via a non-rebreather
• D. Call for assistance

Correct answer: D

Rationale: In the scenario of umbilical cord prolapse during labor, the nurse should first call for assistance. Umbilical cord prolapse is a critical obstetric emergency that requires immediate attention and skilled assistance. Calling for help ensures that additional support is on the way to provide prompt intervention. Placing the client in the Trendelenburg position (Choice A) is no longer recommended as it may worsen the situation. Applying finger pressure to the presenting part (Choice B) can further compress the cord. Administering oxygen (Choice C) is important but should come after addressing the prolapsed cord.

5. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

• A. Evaluate the firmness of the uterus.
• B. Initiate oxygen therapy via a non-rebreather mask.
• C. Administer oxytocin infusion.
• D. Obtain a type and crossmatch.

Correct answer: A

Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

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