Nursing Elites

1. A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?

• A. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.
• B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
• C. Ask the mother to lie still while both the FHR and the radial pulse rate are counted.
• D. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds.

Correct answer: B

Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse. Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate. Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR. Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart. Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.

2. When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?

• A. It is less painful for the client.
• B. Palpation and percussion can increase peristalsis.
• C. It identifies any potential areas of abdominal tenderness.
• D. It gives the client more time to become comfortable with the examiner.

Correct answer: B

Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.

3. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?

• A. Do you normally experience menstrual cramps with your periods?
• B. Do you smoke cigarettes?
• C. Are you currently dieting?
• D. Do you engage in strenuous exercise, such as jogging?

Correct answer: B

Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.

4. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

5. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:

• A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
• B. "Some studies show that ginseng enhances in vitro sperm motility."?
• C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
• D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?

Correct answer: B

Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.

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