Nursing Elites

1. 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.

2. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

3. The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?

• A. Provide a quiet environment with subdued lighting.
• B. Have calcium gluconate immediately available.
• C. Assess deep tendon reflexes (DTRs) every 4 hours.
• D. Insert a Foley catheter with a urimeter to monitor hourly output.

Correct answer: B

Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects. Providing a quiet environment with subdued lighting may be beneficial for the client's comfort but is not the highest priority in this situation. Assessing deep tendon reflexes every 4 hours is important when administering magnesium sulfate, but it is not the highest priority compared to having calcium gluconate available. Inserting a Foley catheter with a urimeter to monitor hourly output is not the highest priority when preparing to administer magnesium sulfate in this scenario.

4. During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

• A. Recommend explaining the normal physiological changes during pregnancy.
• B. Notify the healthcare provider of the complaint.
• C. Inform her that this is a normal physiological change.
• D. Prepare to provide education on vaginal health.

Correct answer: C

Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.

5. Which intervention is most helpful in relieving postpartum uterine contractions or 'afterpains'?

• A. Lying prone with a pillow on the abdomen.
• B. Using a breast pump.
• C. Massaging the abdomen.
• D. Giving oxytocic medications.

Correct answer: A

Rationale: Lying prone with a pillow on the abdomen is the most helpful intervention in relieving postpartum uterine contractions or 'afterpains.' This position provides counter-pressure and support to the uterus, helping to alleviate discomfort and promote uterine involution. Choice B, using a breast pump, is not effective in relieving afterpains as it focuses on milk expression. Massaging the abdomen (Choice C) may help with discomfort but does not provide the same level of support as lying prone with a pillow. Giving oxytocic medications (Choice D) is not typically the first-line intervention for afterpains unless there are specific medical indications.

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