Nursing Elites

1. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

• A. Administer oxygen
• B. Change the client's position
• C. Increase IV fluids
• D. Call the healthcare provider

Correct answer: B

Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps improve placental blood flow, reducing stress on the fetus. Administering oxygen may be necessary if changing position does not resolve the decelerations. Increasing IV fluids is not the priority in this situation as it won't directly address the cause of late decelerations. Calling the healthcare provider should be done after immediate interventions like changing the client's position have been implemented and assessed.

2. A nurse enters a patient's room and finds the client pulseless. The living will requests no resuscitation be performed, but the provider has not written the prescription. What action should the nurse take?

• A. Notify the family.
• B. Begin CPR.
• C. Await further instructions from the provider.
• D. Document the event.

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. Even though the living will requests no resuscitation, without a written do-not-resuscitate (DNR) order from the provider, the nurse is ethically and legally bound to initiate CPR to provide life-saving measures until further confirmation is obtained. Notifying the family (Choice A) may cause a delay in providing immediate care. Waiting for further instructions (Choice C) can be time-consuming and compromise patient outcomes. Documenting the event (Choice D) is important but should follow after initiating CPR to ensure patient safety and adherence to protocols.

3. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post-maturity
• D. Head compression

Correct answer: D

Rationale: When early decelerations are noted on the fetal monitor tracing, it indicates fetal head compression, which is typically a benign finding associated with the progress of labor. Early decelerations mirror the uterine contractions and are often not a cause for concern as they are a normal response to fetal head compression during contractions. Choices A, B, and C are incorrect as they do not align with the expected outcome of early decelerations. Fetal hypoxia, abruptio placentae, and post-maturity would present with different patterns on the fetal monitor tracing and would require different interventions.

4. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

• A. Administer oxytocin to the client via intravenous infusion
• B. Apply oxygen at 2 L/min via nasal cannula
• C. Prepare for insertion of an intrauterine pressure catheter
• D. Assist the client into the knee-chest position

Correct answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.

5. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?

• A. I cannot change my instructions once they are made
• B. My doctor will need to approve my advance directives
• C. I need an attorney to witness my signature on the advance directives
• D. I have the right to refuse treatment

Correct answer: D

Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement indicates an understanding of advance directives because advance directives allow individuals to express their treatment preferences, including the right to refuse treatment if they choose to do so. Choice A is incorrect because individuals can update or change their advance directives as needed. Choice B is incorrect because advance directives are based on the individual's preferences, not the doctor's approval. Choice C is incorrect as witnessing an advance directive typically requires a witness who is not an attorney, depending on the state's specific requirements.

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