Nursing Elites

1. A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?

• A. The procedure typically takes 10 to 30 minutes.
• B. She may need to drink fluids before the test and may not void until the test has been completed.
• C. A probe coated with gel will be inserted into the vagina.
• D. She will be positioned on her back, with her head elevated and turned slightly to one side.

Correct answer: B

Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.

2. A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:

• A. is pregnant.
• B. is immunocompromised.
• C. is allergic to neomycin.
• D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.

3. What is the most appropriate initial action for a newborn infant with low blood glucose?

• A. Ask the registered nurse to draw another blood sample in 2 hours and repeat the test
• B. Contact the healthcare provider
• C. Contact the registered nurse
• D. Document the results in the newborn's medical record

Correct answer: C

Rationale: The blood glucose level for a newborn infant should remain greater than 40 mg/dL to prevent permanent brain damage. When dealing with low blood glucose in a newborn, the most appropriate initial action is to contact the registered nurse. The nurse will obtain prescriptions regarding feeding the infant with low blood glucose and follow agency policies on feeding infants in such conditions. It is common practice to feed the infant if the glucose level is 40 mg/dL or less. Asking the registered nurse to draw another blood sample in 2 hours and repeating the test is not the most appropriate immediate action, as timely intervention is crucial in this situation. Contacting the healthcare provider may cause unnecessary delays since the registered nurse is usually the first point of contact for immediate actions in this scenario. Documenting the results in the newborn's medical record is essential, but it is not the initial step in managing low blood glucose in a newborn.

4. When determining a fetal heart rate (FHR) and noting accelerations from the baseline rate when the fetus is moving, a nurse interprets this finding as:

• A. A reassuring sign
• B. An indication of the need to contact the physician
• C. An indication of fetal distress
• D. A nonreassuring sign

Correct answer: A

Rationale: When a nurse notes accelerations from the baseline rate of the fetal heart rate, particularly when they occur with fetal movement, it is considered a reassuring sign. This indicates a healthy response to fetal activity. Reassuring signs in FHR monitoring include an average rate between 120 and 160 beats/min at term, a regular rhythm with slight fluctuations, accelerations from the baseline rate (often associated with fetal movement), and the absence of decreases from the baseline rate. Choices B, C, and D are incorrect because accelerations in FHR with fetal movement are not indicative of the need to contact the physician, fetal distress, or a nonreassuring sign. These signs would typically be associated with other abnormal FHR patterns that would warrant further assessment and intervention.

5. A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent?

• A. Using a latex condom is a good method for reducing the risk of sexually transmitted infections (STIs).
• B. The only way to reduce the risk of transmission of STIs is abstinence.
• C. A spermicide needs to be used along with a condom to prevent transmission of STIs.
• D. Using a latex condom can reduce the risk of transmission of STIs.

Correct answer: D

Rationale: The correct answer is that using a condom during intercourse can reduce the risk of STI transmission. Abstinence is a way to prevent STIs, but not the only way. Using a spermicide along with a condom can help prevent pregnancy, not STIs. While condoms may fail to prevent pregnancy, they are effective in reducing the risk of STI transmission. Therefore, using a latex condom for pregnancy prevention is not directly related to preventing the transmission of STIs.

Similar Questions