Nursing Elites

1. A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats/min. On the basis of this finding, which priority action should the nurse take?

• A. Continuing to check the client's vital signs every 15 minutes
• B. Notifying the registered nurse immediately
• C. Checking the client's uterine fundus
• D. Documenting the vital signs in the client's medical record

Correct answer: C

Rationale: During the fourth stage of labor, the woman's vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, as the heart beats faster to compensate for reduced blood volume. The blood pressure decreases as blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is a uterus that is not firmly contracting and compressing open vessels at the placental site. Therefore, the nurse should check the client's uterine fundus for firmness, height, and positioning. Checking the uterine fundus is the priority action as it helps determine if the client is bleeding excessively. Notifying the registered nurse immediately is not necessary unless the cause of bleeding is unclear and needs further intervention. Continuing to check vital signs without addressing the potential issue will delay necessary intervention. Documenting findings is important, but not the immediate priority when faced with a potential emergency situation like postpartum hemorrhage.

2. After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?

• A. Hib
• B. IPV
• C. MMR
• D. DTaP

Correct answer: D

Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.

3. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

4. The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:

• A. disclose the information before the child knows or suspects.
• B. be comfortable with your sexual preference first.
• C. have the discussion in a quiet place where interruptions are unlikely.
• D. explain how your relationship with the child changes because of the discussion

Correct answer: D

Rationale: The correct answer is to explain how your relationship with the child changes because of the discussion. Children of gay and lesbian parents should be reassured that their relationship with their parent will not change due to the disclosure. Choices A, B, and C are all important aspects of the disclosure process. It is crucial to disclose the information before the child knows or suspects, be comfortable with your sexual preference first, and have the discussion in a quiet place to ensure a safe and open environment for communication. Explaining how the relationship with the child changes might create unnecessary anxiety or confusion. Children may have different reactions based on their age, understanding, and environment. Therefore, it is essential to maintain a sense of stability and security in the parent-child relationship while addressing any questions or concerns that may arise.

5. When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?

• A. It is less painful for the client.
• B. Palpation and percussion can increase peristalsis.
• C. It identifies any potential areas of abdominal tenderness.
• D. It gives the client more time to become comfortable with the examiner.

Correct answer: B

Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.

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