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 caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?

• A. Tell the mother to follow the iron drops with infant formula instead of orange juice.
• B. Suggest placing the iron drops in the orange juice and then feeding the infant.
• C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
• D. Give the mother positive feedback about the way she administered the medication.

Correct answer: D

Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver. Choices A, B, and C are incorrect because they do not align with the beneficial practice of administering iron drops with orange juice, which enhances iron absorption. Changing the method of administration based on incorrect assumptions or instructing to withhold feeding after giving iron drops is unnecessary and not evidence-based.

3. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

• A. 3+ deep tendon reflexes and hyperreflexia.
• B. Periorbital edema, flashing lights, and aura.
• C. Epigastric pain in the third trimester.
• D. Recent decreased urinary output.

Correct answer: A

Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.

4. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?

• A. Which symptom did you experience first?
• B. Are you consuming large amounts of salty foods?
• C. Have you traveled to a foreign country recently?
• D. Do you have a history of rheumatic fever?

Correct answer: D

Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.

5. Upon admission to the prenatal clinic, a 23-year-old woman informs the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What is this client's expected date of delivery (EDD)?

• A. November 22.
• B. November 8.
• C. December 22.
• D. October 22.

Correct answer: A

Rationale: To determine the expected date of delivery (EDD) using Nägele's rule, add 7 days to the first day of the last menstrual period (LMP) which is February 15, resulting in February 22. Then, subtract 3 months from February 22, which gives November 22 as the estimated due date.

Similar Questions