Nursing Elites

1. The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

• A. Elicit a positive scarf sign on the affected side.
• B. Observe for an asymmetrical Moro (startle) reflex.
• C. Watch for swelling of fingers on the affected side.
• D. Note paralysis of the affected extremity and muscles.

Correct answer: B

Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.

2. When a client delivers a viable infant but experiences excessive uncontrolled vaginal bleeding after the IV Pitocin infusion, what information is most important for the nurse to provide when notifying the healthcare provider?

• A. Maternal blood pressure
• B. Estimated blood loss
• C. Length of labor
• D. Amount of IV fluids administered

Correct answer: A

Rationale: In a situation where a client is experiencing excessive uncontrolled vaginal bleeding post-delivery, the most crucial information for the nurse to provide the healthcare provider is the maternal blood pressure. Maternal blood pressure can help assess the severity of the bleeding and guide immediate interventions to stabilize the client's condition. Estimated blood loss, length of labor, and amount of IV fluids administered are important pieces of information but in this scenario, maternal blood pressure takes precedence as it directly indicates the client's current hemodynamic status.

3. The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

• A. A gravida 6, para 5 who is 38 years of age and in early labor.
• B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
• C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
• D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.

Correct answer: D

Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.

4. What is the most important assessment for the healthcare provider to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

• A. Maternal blood pressure.
• B. Level of pain sensation
• C. Station of presenting part.
• D. Variability of fetal heart rate.

Correct answer: A

Rationale: Following the administration of epidural anesthesia, the most crucial assessment for the healthcare provider to conduct is monitoring maternal blood pressure. Epidural anesthesia can lead to hypotension as a common side effect, which can have significant implications for both the mother and the fetus. Therefore, close monitoring of maternal blood pressure is essential to detect and manage any hypotensive episodes promptly. Choices B, C, and D are important assessments during labor and delivery, but in this specific scenario of post-epidural anesthesia, monitoring maternal blood pressure takes precedence due to the potential risk of hypotension.

5. A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn?

• A. Length of labor and method of delivery.
• B. Infant's condition at birth and treatment received.
• C. Feeding method chosen by the parents.
• D. History of drugs given to the mother during labor.

Correct answer: B

Rationale: When a full-term infant is transferred to the nursery, the most crucial information for the LPN/LVN to receive for immediate care planning is the infant's condition at birth and any treatments received. This data helps in determining the initial care needs and monitoring requirements for the newborn. Choices A, C, and D are not as critical as the infant's condition at birth and treatment received. The length of labor and method of delivery may provide background information but may not be as essential for immediate care planning. The feeding method chosen by the parents and the history of drugs given to the mother during labor are important but do not take precedence over knowing the infant's condition and treatment received.

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