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. The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

• A. Insert an internal fetal monitor.
• B. Assess for cervical changes q1h.
• C. Monitor bleeding from IV sites.
• D. Perform Leopold's maneuvers.

Correct answer: C

Rationale: Monitoring for bleeding from IV sites is the priority intervention in this situation. The dark red vaginal bleeding, uterine tension, and other assessment findings suggest a potential placental abruption. Monitoring bleeding from IV sites can help detect coagulopathy, which may be associated with placental abruption. Options A, B, and D are not the most appropriate interventions in this scenario. Inserting an internal fetal monitor, assessing for cervical changes, and performing Leopold's maneuvers are not the priority actions when dark red vaginal bleeding and uterine tension are present, indicating a potential emergency situation.

3. The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?

• A. Heat loss.
• B. Fluid balance.
• C. Bleeding tendencies.
• D. Hypoglycemia.

Correct answer: A

Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.

4. 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.

5. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?

• A. Allow the child to eat any food desired and tolerated.
• B. Provide small, frequent meals that are high in protein and calories.
• C. Offer the child preferred foods and avoid foods that are not well-tolerated.
• D. Consult with a dietitian to provide appropriate nutritional support.

Correct answer: B

Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.

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