Nursing Elites

1. The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?

• A. Litmus paper.
• B. Fetal scalp electrode.
• C. A sterile glove.
• D. Needle and Thread

Correct answer: C

Rationale: For performing an amniotomy, the nurse should have a sterile glove to maintain asepsis and an amniotic hook to rupture the amniotic sac. Litmus paper is not required for this procedure, and a fetal scalp electrode is used for fetal monitoring, not for an amniotomy.

2. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?

• A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
• B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
• C. I know you're upset. Would you like to talk about some activities you could do while in bed?
• D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.

Correct answer: A

Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.

3. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

• A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
• B. Growth and development have been abnormal since birth.
• C. Muscular strength can be regained with physical exercise and therapy.
• D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.

Correct answer: A

Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.

4. 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.

5. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

• A. Graph the daily weight for the past week.
• B. Decrease IV flow rate.
• C. Assess bilateral lung sounds.
• D. Restrict intake of oral fluids.

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

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