Nursing Elites

1. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?

• A. You do not need to have a full bladder for the procedure
• B. You will not receive magnesium sulfate before the procedure
• C. The procedure will take longer than 30 minutes to complete
• D. You should report if you experience any contractions after the procedure

Correct answer: D

Rationale: The correct statement to include in the teaching about amniocentesis is that the client should report if they experience any contractions after the procedure. This is crucial because contractions could indicate preterm labor or other complications following the amniocentesis. Choices A and B are incorrect as a full bladder is not required for the procedure, and magnesium sulfate is not typically given before an amniocentesis. Choice C is incorrect as the procedure usually takes about 20-30 minutes to complete.

2. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

• A. Prepare the equipment necessary to initiate an amnioinfusion
• B. Administer oxygen at 10 L/min via a non-rebreather face mask
• C. Discontinue the infusion of oxytocin
• D. Place the client in a left lateral position

Correct answer: C

Rationale: The correct first action for the nurse to take is to discontinue the infusion of oxytocin. Oxytocin can lead to uterine hyperstimulation and fetal distress, contributing to variable decelerations in fetal heart rate. By stopping the oxytocin infusion, the nurse can promptly assess and manage the fetal heart rate. Choice A, preparing for amnioinfusion, is not the priority when faced with recurrent variable decelerations. Choice B, administering oxygen, is important but addressing the oxytocin infusion issue takes precedence. Choice D, placing the client in a left lateral position, is beneficial for optimizing fetal oxygenation but discontinuing oxytocin is the initial step in managing variable decelerations.

3. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

• A. WBC count 11,000/mm³
• B. Hgb 11.2 g/dL
• C. Hct 34%
• D. Platelets 140,000/mm³

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

4. A healthcare professional is assessing a client for signs of depression. Which of the following findings should the healthcare professional look for?

• A. Increased energy
• B. Changes in sleep patterns
• C. Weight loss
• D. Both B and C

Correct answer: D

Rationale: When assessing a client for signs of depression, healthcare professionals should look for changes in sleep patterns and weight loss. These are common symptoms associated with depression. Increased energy (choice A) is not typically a sign of depression, as individuals with depression often experience fatigue and a lack of energy. Therefore, choices A, B, and C are incorrect, making choice D the correct answer.

5. A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is hyperventilating, leading to excessive elimination of carbon dioxide. As a result, the PaCO2 decreases, causing a decrease in hydrogen ion concentration and an increase in pH, resulting in respiratory alkalosis. Choice A, Respiratory acidosis, is incorrect because the ABG results show a low PaCO2, not an elevated one. Choices C and D, Metabolic acidosis and Metabolic alkalosis, do not align with the ABG results provided, which point towards a respiratory, not metabolic, imbalance.

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