Nursing Elites

1. When should the LPN/LVN encourage the laboring client to begin pushing?

• A. When there is only an anterior or posterior lip of the cervix left.
• B. When the client describes the need to have a bowel movement.
• C. When the cervix is completely dilated.
• D. When the cervix is completely effaced.

Correct answer: C

Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal. Choices A, B, and D are incorrect because pushing before complete dilation can be harmful and may not effectively help in the descent of the baby. The presence of an anterior or posterior lip of the cervix, the urge to have a bowel movement, or complete effacement of the cervix are not indicators for the initiation of pushing during labor.

2. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

• A. Weak cry without tears.
• B. Bulging fontanel.
• C. Visible peristaltic wave.
• D. Palpable mass in the right upper quadrant.

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

3. A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

• A. Perform a sterile vaginal examination to determine dilatation.
• B. Determine fetal position by performing Leopold maneuvers.
• C. Assess the fetal heart rate and client's contraction pattern.
• D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.

Correct answer: C

Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.

4. 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.

5. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

• A. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on.
• B. Use a nipple shield to help the baby latch on.
• C. Try a different breastfeeding position.
• D. Have another person help the mother with breastfeeding.

Correct answer: A

Rationale: In this scenario, the best intervention is to ask the mother to stop feeding, comfort the infant, and then assist her in helping the baby latch on. Stopping the feeding and providing comfort can reduce the infant's frustration and create a calmer environment for successful breastfeeding. Choice B, using a nipple shield, may not address the underlying issue causing the baby's difficulty latching. Choice C, trying a different breastfeeding position, can be attempted after the baby is calm and ready to latch. Choice D, having another person help, may not be necessary if the mother can be guided effectively on latching techniques.

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