Nursing Elites

1. Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child’s plan of care?

• A. Monitor serum glucose for adjustment in the infusion rate of regular insulin (Novolin R).
• B. Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N).
• C. Demonstrate to the parents how to program an insulin pen for daily glucose regulation.
• D. Consult with the healthcare provider about the use of insulin detemir (Levemir Flex Pen).

Correct answer: A

Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA. Choice B is incorrect as it focuses on a different type of insulin and compliance schedule without addressing the immediate needs of managing DKA. Choice C is not the priority action and involves educating parents on a different method of insulin administration. Choice D is also not the most important action as it suggests consulting with the healthcare provider about a different type of insulin rather than focusing on immediate glucose monitoring for insulin adjustment in DKA management.

2. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?

• A. The thyroxine level is low because the TSH level is high.
• B. High thyroxine levels do not normally occur in breastfeeding infants.
• C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
• D. The TSH is high because of the low production of T4 by the thyroid.

Correct answer: D

Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.

3. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

• A. Turn off the oxytocin infusion.
• B. Reposition the fetal monitor transducers.
• C. Decrease the rate of the oxytocin infusion.
• D. Alert the charge nurse about the patient's condition.

Correct answer: A

Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.

4. A client addicted to heroin and newly pregnant asks a nurse about ensuring her baby's health while on methadone. What should the nurse advise?

• A. Sign up for group therapy sessions.
• B. Discontinue the methadone right away.
• C. Start prenatal care as soon as possible.
• D. Describe genetic testing protocol.

Correct answer: C

Rationale: Initiating prenatal care promptly is essential for monitoring the well-being of both the mother and the fetus, particularly in high-risk pregnancies involving substance use. Early prenatal care allows for timely interventions, education, and support to promote a healthier pregnancy and birth outcomes. Choice A is incorrect because while group therapy may be beneficial, initiating prenatal care is more crucial at this stage. Choice B is incorrect as abrupt discontinuation of methadone can be harmful and should be managed under medical supervision. Choice D is incorrect as genetic testing is not the immediate priority in this scenario.

5. A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

• A. Perform a sterile vaginal examination to determine dilatation.
• B. Determine fetal position by performing Leopold maneuvers.
• C. Assess the fetal heart rate and client's contraction pattern.
• D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.

Correct answer: C

Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.

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