Nursing Elites

1. 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.

2. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?

• A. Notify the healthcare provider immediately.
• B. Suction the infant's nares, then the oral cavity.
• C. Check the infant's oxygen saturation rate.
• D. Position the infant on the right side.

Correct answer: C

Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.

3. Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?

• A. The client's readiness to learn.
• B. The client's educational background.
• C. The order in which the information is presented.
• D. The extent to which the pregnancy was planned.

Correct answer: A

Rationale: The client's readiness to learn is the most critical factor influencing successful teaching of the gravid client. When a client is receptive and motivated to learn, they are more likely to engage with the information provided, leading to better understanding and retention.

4. The client is 30 weeks pregnant and experiencing preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?

• A. Betamethasone (Celestone).
• B. Magnesium sulfate.
• C. Terbutaline (Brethine).
• D. Ampicillin.

Correct answer: A

Rationale: Betamethasone (Celestone) is the medication of choice to promote fetal lung maturity in cases of preterm labor. It helps accelerate surfactant production in the fetal lungs, reducing the risk of respiratory distress syndrome. Administering betamethasone to the mother can improve the baby's lung function and overall outcome if preterm birth occurs. Magnesium sulfate is commonly used to prevent seizures in preeclampsia or eclampsia. Terbutaline is a tocolytic agent used to suppress preterm labor contractions. Ampicillin is an antibiotic used for various bacterial infections but does not promote fetal lung maturity.

5. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?

• A. CO2 combining power
• B. Calcium
• C. Sodium
• D. Chloride

Correct answer: B

Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.

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