Nursing Elites

1. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

• A. Increase the infusion rate every 30 to 60 minutes.
• B. Maintain the client in a supine position.
• C. Titrate the infusion rate by 4 milliunits/min.
• D. Limit IV intake to 4 L per 24 hours.

Correct answer: A

Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.

2. The nurse is receiving a report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?

• A. Begin a pad count
• B. Prepare to start an IV
• C. Take the client's temperature
• D. Monitor amniotic fluid for meconium

Correct answer: C

Rationale: The priority nursing action when a client with ruptured membranes is admitted to the labor and delivery suite is to take the client's temperature. This is crucial to assess for infection, especially when the duration of membrane rupture is unknown. Beginning a pad count, preparing to start an IV, and monitoring amniotic fluid for meconium are important actions but are not as immediate or critical as assessing for infection through temperature measurement.

3. A newborn is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

• A. Apply a thin layer of lotion to the newborn's skin every 8 hours.
• B. Give the newborn 1 oz of glucose water every 4 hours.
• C. Ensure the newborn's eyes are closed beneath the shield.
• D. Dress the newborn in a thin layer of clothing during therapy.

Correct answer: C

Rationale: During phototherapy using a lamp, it is crucial to protect the newborn's eyes from the light to prevent damage. Closing the newborn's eyes beneath the shield is essential for this purpose. Applying lotion to the skin (Choice A) is not recommended as it can intensify the effects of the phototherapy. Giving glucose water (Choice B) is unrelated to the phototherapy process and is not indicated. Dressing the newborn in clothing (Choice D) may hinder the effectiveness of the phototherapy by blocking the light exposure to the skin.

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 primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?

• A. Blood pressure (BP) increased to 138/86 mm Hg.
• B. Weight gain of 0.5 kg during the past 2 weeks.
• C. Dipstick value of 3+ for protein in her urine.
• D. Pitting pedal edema at the end of the day.

Correct answer: C

Rationale: The correct answer is C. Proteinuria, indicated by a dipstick value of 3+ in the urine, is a significant concern in a patient being monitored for preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, and a value of 3+ signifies a substantial amount of protein in the urine, warranting further evaluation. While an increase in blood pressure to 138/86 mm Hg is slightly elevated, it does not meet the diagnostic threshold for severe hypertension in preeclampsia. A weight gain of 0.5 kg over 2 weeks is within normal limits and not as concerning as significant rapid weight gain. Pitting pedal edema, though common in pregnancy, is not a specific indicator of preeclampsia and is considered a less concerning finding compared to significant proteinuria.

Similar Questions