Nursing Elites

1. A client with preeclampsia is receiving magnesium sulfate by continuous IV infusion. Which finding should the nurse report to the provider?

• A. Blood pressure 148/94 mm Hg
• B. Respiratory rate 14/min
• C. Urinary output 20 mL/hr
• D. 2+ deep tendon reflexes

Correct answer: C

Rationale: In a client with preeclampsia receiving magnesium sulfate, a urinary output of 20 mL/hr is a concerning finding as it may indicate renal impairment or magnesium toxicity. Adequate urinary output is crucial for eliminating excess magnesium and preventing toxicity. The nurse should report this finding to the provider for further evaluation. A blood pressure of 148/94 mm Hg is elevated but expected in a client with preeclampsia. A respiratory rate of 14/min is within the normal range. 2+ deep tendon reflexes are a common finding in clients receiving magnesium sulfate and are not a cause for concern unless they progress to hyperreflexia or clonus.

2. A client with hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory tests should the nurse anticipate?

• A. Urine Ketones
• B. Rapid plasma reagin
• C. Prothrombin time
• D. Urine culture

Correct answer: A

Rationale: Urine ketones should be anticipated as a laboratory test for a client with hyperemesis gravidarum because it helps assess the severity of dehydration and malnutrition, which are common complications of this condition. Choice B, rapid plasma reagin, is a test for syphilis and is not relevant to hyperemesis gravidarum. Choice C, prothrombin time, is a measure of blood clotting function and is not typically indicated for hyperemesis gravidarum. Choice D, urine culture, is used to identify bacteria in the urine and is not directly related to assessing dehydration and malnutrition in clients with hyperemesis gravidarum.

3. A client who is receiving prenatal care is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?

• A. Group B strep culture
• B. 1-hour glucose tolerance test
• C. Rubella titer
• D. Blood type and Rh

Correct answer: B

Rationale: The correct answer is B: 1-hour glucose tolerance test. At around 24-28 weeks of gestation, a pregnant individual is typically screened for gestational diabetes. The 1-hour glucose tolerance test helps in identifying elevated blood sugar levels during pregnancy. Choice A, Group B strep culture, is not typically performed at the 24-week appointment but later in the third trimester to screen for Group B streptococcus colonization. Choice C, Rubella titer, is usually checked early in pregnancy to determine immunity to rubella. Choice D, Blood type and Rh, is important for determining the client's blood type and Rh status, but it is usually done earlier in pregnancy and not specifically at the 24-week appointment.

4. A new mother who is a lacto-ovo vegetarian plans to breastfeed her infant. Which information should the nurse provide prior to discharge?

• A. Continue prenatal vitamins with B12 while breastfeeding
• B. Avoid using Lanolin-based nipple cream or ointment
• C. Offer iron-fortified supplemental formula daily
• D. Weigh the baby weekly to evaluate the newborn's growth

Correct answer: A

Rationale: The correct answer is A: 'Continue prenatal vitamins with B12 while breastfeeding.' Vitamin B12 is crucial for lacto-ovo vegetarian mothers to prevent deficiencies in both the mother and the infant. Choice B is incorrect as Lanolin-based nipple cream is safe for use during breastfeeding. Choice C is not necessary unless there are specific indications for iron supplementation. Choice D, weighing the baby weekly, is important for monitoring growth but not specifically related to the mother's diet.

5. A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the healthcare provider?

• A. A pattern of fetal late decelerations.
• B. Fetal heart rate accelerations with fetal movement.
• C. Absence of uterine contractions within 20 minutes.
• D. Spontaneous rupture of membranes.

Correct answer: A

Rationale: The correct answer is A: A pattern of fetal late decelerations. Late decelerations during a contraction stress test are concerning as they indicate uteroplacental insufficiency, which can pose a risk to fetal well-being. Reporting this finding to the healthcare provider is crucial for prompt intervention. Choice B, fetal heart rate accelerations with fetal movement, is a reassuring sign of fetal well-being and does not raise immediate concerns. Choice C, absence of uterine contractions within 20 minutes, may require further assessment but is not as critical as late decelerations. Choice D, spontaneous rupture of membranes, is important but not the most immediate concern during a contraction stress test.

Similar Questions