Nursing Elites

1. A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?

• A. Rh incompatibility
• B. Severe preeclampsia
• C. Placental abruption
• D. Erythroblastosis fetalis

Correct answer: A

Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.

2. A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?

• A. Administer 1 oz of glucose water every 2 hours
• B. Feed the newborn 60 mL of formula every 4 hours
• C. Offer sterile water between feedings
• D. Initiate phototherapy

Correct answer: D

Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.

3. A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. 1+ proteinuria
• B. Blood pressure 144/92 mm Hg
• C. Respiratory rate 22/min
• D. Urine output 20 mL/hr

Correct answer: D

Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.

4. A client at 37 weeks of gestation is scheduled for a nonstress test. What information should the nurse include?

• A. You will be given oxytocin during the test.
• B. You will need to fast for 12 hours before the test.
• C. You will need to drink orange juice before the test.
• D. You will need to have a full bladder during the test.

Correct answer: C

Rationale: The correct answer is C. Drinking orange juice before the nonstress test can increase fetal movement, which is essential for an accurate reading. Choice A is incorrect because oxytocin is not typically administered during a nonstress test. Choice B is incorrect as fasting is not required before this test. Choice D is incorrect as a full bladder is not necessary for a nonstress test.

5. A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should eat foods high in protein before bedtime.
• B. You should avoid consuming liquids with your meals.
• C. You should eat three large meals per day.
• D. You should consume caffeine to help with nausea.

Correct answer: B

Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.

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