Nursing Elites

1. A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?

• A. Dizziness while standing
• B. Sinus tachycardia
• C. Lower back pain
• D. Absent patellar reflexes

Correct answer: D

Rationale: The correct answer is D: Absent patellar reflexes. Absent patellar reflexes can indicate magnesium toxicity, a serious condition that requires immediate intervention to prevent respiratory depression or cardiac arrest. Dizziness while standing (choice A) is common in pregnancy but does not specifically indicate magnesium toxicity. Sinus tachycardia (choice B) can be a normal response to magnesium sulfate but does not indicate toxicity. Lower back pain (choice C) is common in pregnancy and not specifically associated with magnesium toxicity.

2. After a mother was diagnosed with gonorrhea immediately after delivery, what is an important goal of the nurse when providing care for her baby?

• A. Prevent the development of ophthalmia neonatorum.
• B. Lubricate the eyes.
• C. Prevent the development of infection.
• D. Teach about the risks of breastfeeding with gonorrhea.

Correct answer: A

Rationale: The correct answer is A: Prevent the development of ophthalmia neonatorum. When a mother has gonorrhea, the baby can be infected during delivery, leading to ophthalmia neonatorum, which can cause permanent blindness. Therefore, it is crucial for the nurse to prevent this condition by treating the baby's eyes with an antibiotic prophylactically after birth. Choice B, lubricating the eyes, is not the primary goal in this situation as preventing infection takes precedence. Choice C, preventing the development of infection, is too broad and does not specifically address the potential complication of ophthalmia neonatorum. Choice D, teaching about the risks of breastfeeding with gonorrhea, is important but not the immediate goal in this scenario where preventing ophthalmia neonatorum and potential blindness is the priority.

3. 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.

4. What information should the nurse include when teaching a client at 41 weeks of gestation about a non-stress test?

• A. This test will confirm fetal lung maturity.
• B. This test will determine the adequacy of placental perfusion.
• C. This test will detect fetal infection.
• D. This test will predict maternal readiness for labor.

Correct answer: B

Rationale: The correct answer is B: 'This test will determine the adequacy of placental perfusion.' The non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to its own movements. It helps determine if the fetus is receiving enough oxygen and nutrients through placental perfusion. Choice A is incorrect because confirming fetal lung maturity is typically determined through tests like amniocentesis, not the non-stress test. Choice C is incorrect because detecting fetal infection is not the primary purpose of a non-stress test. Choice D is incorrect because predicting maternal readiness for labor is not the purpose of the non-stress test; it focuses on fetal well-being.

5. Which information regarding the care of antepartum women with cardiac conditions is most important for the nurse to understand?

• A. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor.
• B. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms.
• C. Women with class III cardiac disease should get 8 to 10 hours of sleep every day and limit housework, shopping, and exercise.
• D. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.

Correct answer: B

Rationale: Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32 of gestation, when hemodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less-than-ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can perform limited normal activities with discretion, although they still need a good amount of sleep.

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