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 pregnant client mentions in her history that she changes the cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe?

• A. Biophysical profile
• B. Fern test
• C. Amniocentesis
• D. TORCH screening

Correct answer: D

Rationale: The correct answer is D, TORCH screening. TORCH screening is done to detect infections such as toxoplasmosis, which can be contracted from handling cat litter and is harmful during pregnancy. Biophysical profile (choice A) is a prenatal ultrasound evaluation. Fern test (choice B) is used to assess for amniotic fluid leakage. Amniocentesis (choice C) involves taking a sample of amniotic fluid to test for genetic abnormalities and certain infections, not specifically related to toxoplasmosis from cat litter.

3. Is color blindness a sex-linked abnormality?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: A

Rationale: The correct answer is A: TRUE. Color blindness is indeed a sex-linked abnormality as it is often associated with genes on the X chromosome. Since males have only one X chromosome, they are more likely to inherit color blindness if the gene is present. This makes color blindness more common in males. Choice B (FALSE) is incorrect because color blindness is linked to the X chromosome. Choices C (Sometimes) and D (Always) are incorrect as color blindness is consistently tied to the X chromosome.

4. A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

• A. Obtain a blood sample for a serum glucose level
• B. Feed the newborn immediately
• C. Administer 50 mL of dextrose solution IV
• D. Reassess the blood glucose level prior to the next feeding

Correct answer: D

Rationale: A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn. Reassessing the blood glucose level prior to the next feeding ensures ongoing monitoring without unnecessary intervention. Obtaining a blood sample for a serum glucose level (Choice A) is not necessary as the initial reading is normal. Feeding the newborn immediately (Choice B) may not be indicated and could lead to unnecessary interventions. Administering dextrose solution IV (Choice C) is not warranted as the glucose level is within the normal range and does not require immediate correction.

5. A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment warrants immediate intervention by the nurse?

• A. Fetal Heart rate 60 beats per minute
• B. Ruptured amniotic membrane
• C. Onset of uterine contractions
• D. Leaking amniotic fluid

Correct answer: A

Rationale: A fetal heart rate of 60 beats per minute is significantly below the normal range (110-160 bpm) and indicates fetal distress, requiring immediate intervention. This low heart rate can be a sign of fetal compromise or distress, necessitating urgent evaluation and intervention to ensure the well-being of the fetus. Choices B, C, and D do not indicate immediate fetal distress requiring urgent intervention. Ruptured amniotic membrane, onset of uterine contractions, and leaking amniotic fluid are important assessments but do not present an immediate threat to the fetus's life like a severely low fetal heart rate.

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