Nursing Elites

1. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

• A. Check the client's temperature.
• B. Report the findings to the nurse-midwife.
• C. Obtain a sample of the amniotic fluid for laboratory analysis.
• D. Document the findings.

Correct answer: Document the findings.

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client’s temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

2. A nurse is determining the estimated date of delivery for a pregnant client using Nagele’s rule and notes documentation that the date of the client’s last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be which date?

• A. May 30, 2014
• B. June 6, 2014
• C. July 6, 2014
• D. May 6, 2014

Correct answer: June 6, 2014

Rationale: Nagele’s rule is a method used to estimate the date of delivery for pregnant clients. The rule involves subtracting 3 months and adding 7 days to the date of the first day of the last normal menstrual period, then adjusting the year. Subtracting 3 months from August 30, 2013, brings the date to May 30, 2013; adding 7 days results in June 6, 2013. Finally, after correcting the year, the estimated date of delivery is June 6, 2014. Therefore, the correct answer is June 6, 2014. Choices A, C, and D are incorrect because they do not follow the accurate calculation based on Nagele's rule.

3. A nurse is explaining a nonstress test to a pregnant client. The nurse explains that the results are nonreactive if which finding is noted on the electronic monitoring recording strip?

• A. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats/min above baseline and lasting 15 seconds from baseline to baseline
• B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats/min for 15 seconds
• C. Acceleration of the FHR by 25 to 30 beats/min for at least 15 seconds in response to fetal movement
• D. Absence of accelerations after fetal movement

Correct answer: Absence of accelerations after fetal movement

Rationale: The correct answer is 'Absence of accelerations after fetal movement.' In a nonreactive (nonreassuring) stress test, the monitor recording would not show accelerations after fetal movement within a 40-minute period. This absence of accelerations indicates a nonreactive result. Choices A, B, and C describe different patterns of fetal heart rate accelerations that are not indicative of a nonreactive result in a nonstress test, making them incorrect. Choice A describes the characteristics of a reactive (reassuring) result, where there should be at least two fetal heart accelerations within a 20-minute period, peaking at least 15 beats/min above the baseline, and lasting 15 seconds from baseline to baseline. Choice B incorrectly states 'Accelerations without fetal movement,' which is contradictory. Choice C describes an acceleration response to fetal movement, which does not signify a nonreactive result.

4. The LPN is caring for a client taking Lipitor (Atorvastatin). Which of these statements would indicate that the client may need reinforced teaching?

• A. “I take my Lipitor with a glass of milk after my breakfast.”
• B. “I take my Lipitor and wait 30 minutes before taking my other medications.”
• C. “I take my Lipitor 30 minutes after I eat something.”
• D. “I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.”

Correct answer: “I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.”

Rationale: The correct answer is, 'I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.' This statement indicates a need for reinforced teaching because grapefruit juice should be avoided when taking Lipitor. Grapefruit juice blocks the enzymes needed to break down the drug, which leads to excessive amounts of the drug in the body. Choices A, B, and C show appropriate timing and administration of Lipitor, whereas choice D poses a potential risk due to the interaction between grapefruit juice and Lipitor.

5. When inspecting the client’s eyelids for ptosis, the nurse is checking for which abnormality?

• A. Drooping
• B. Pupil dilation
• C. Pupil constriction
• D. Deviation of ocular movements

Correct answer: Drooping

Rationale: When a nurse inspects a client’s eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client’s eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.

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