Nursing Elites

1. During a non-stress test (NST) at 41-weeks gestation, the LPN/LVN notes that the client is not experiencing contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are present. What action should the nurse take?

• A. Check the client for urinary bladder distention.
• B. Notify the healthcare provider of the nonreactive results.
• C. Have the mother stimulate the fetus to move.
• D. Ask the client if she has felt any fetal movement.

Correct answer: D

Rationale: In this scenario, the nurse should ask the client if she has felt any fetal movement. This action is important as assessing for fetal movement can help determine if the absence of FHR accelerations is attributed to fetal sleep or decreased fetal activity. It is crucial to gather information directly from the client to aid in the assessment and decision-making process. This approach can provide valuable insights into the fetal well-being and guide further interventions if needed.

2. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

3. In planning care for a client at 30-weeks gestation experiencing preterm labor, what maternal prescription is most important in preventing this fetus from developing respiratory syndrome?

• A. Betamethasone (Celestone) 12mg deep IM.
• B. Butorphanol 1mg IV push q2h PRN pain.
• C. Ampicillin 1g IV push q8h.
• D. Terbutaline (Brethine) 0.25mg subcutaneously q15 minutes x3.

Correct answer: A

Rationale: The administration of Betamethasone (Celestone) is crucial in cases of preterm labor to promote fetal lung maturation and reduce the risk of respiratory distress syndrome in the newborn. Betamethasone helps enhance the production of surfactant in the fetal lungs, improving their functionality and decreasing the likelihood of respiratory complications upon birth. Butorphanol is an analgesic and not indicated for preventing respiratory syndrome in preterm infants. Ampicillin is an antibiotic used for infection prevention and treatment, not for fetal lung maturation. Terbutaline is a tocolytic agent used to inhibit contractions, but it does not have a direct effect on fetal lung maturity.

4. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

5. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit
• B. Administer the scheduled dose
• C. Calculate the safe dose range
• D. Review the serum digoxin level

Correct answer: B

Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.

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