Nursing Elites

1. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

• A. Notify the healthcare provider of the assessment findings.
• B. Administer analgesics as prescribed.
• C. Increase the client’s fluid intake.
• D. Monitor the client’s vital signs every hour.

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

2. At 40-weeks gestation, a client presents to the obstetrical floor indicating that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. Which information is most important for the nurse to obtain?

• A. Color and consistency of fluid.
• B. Estimated amount of fluid.
• C. Any odor noted when membranes ruptured.
• D. Time the membranes ruptured.

Correct answer: A

Rationale: The color and consistency of the amniotic fluid are crucial to assess for the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can suggest fetal compromise and the need for further evaluation and monitoring. The estimated amount of fluid is less critical than assessing for meconium. While noting any odor when the membranes ruptured may provide some information, it is not as crucial as assessing for meconium. The time the membranes ruptured is important for documenting the timeline but does not directly impact immediate patient care like assessing for fetal distress.

3. The healthcare provider is reviewing the serum laboratory findings for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory result should be reported to the healthcare provider immediately?

• A. Bilirubin of 1.5 mg/dl.
• B. Glucose of 80 mg/dl.
• C. Potassium of 4.5 mEq/L.
• D. Sodium of 119 mEq/L.

Correct answer: D

Rationale: Low sodium levels in congenital adrenal hyperplasia can indicate salt-wasting crisis, which is a life-threatening emergency requiring immediate medical attention. Monitoring sodium levels is crucial to prevent complications such as dehydration and shock in these patients.

4. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?

• A. Insert a straight urinary catheter to drain the bladder.
• B. Scan the bladder for urinary retention.
• C. Palpate the suprapubic area for fetal head position.
• D. Test the fluid with a nitrazine strip.

Correct answer: D

Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.

5. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

• A. Suction the oral and nasal passages.
• B. Give oxygen by positive pressure.
• C. Stimulate the infant to cry.
• D. Turn the infant onto the right side.

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

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