Nursing Elites

1. The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client?

• A. Clonidine hydrochloride
• B. Carbamazepine
• C. Furosemide
• D. Magnesium sulfate

Correct answer: D

Rationale: In the scenario presented, the client is exhibiting signs and symptoms of severe preeclampsia, including hypertension, proteinuria, facial and hand swelling, visual disturbances, and a severe headache. The medication of choice for preventing seizures in preeclampsia is magnesium sulfate. This drug helps to prevent and control seizures in clients with preeclampsia, making it the most appropriate option for this client. Clonidine hydrochloride (Choice A) is an antihypertensive medication used for managing hypertension but is not the first-line treatment for preeclampsia. Carbamazepine (Choice B) is an anticonvulsant used for seizure disorders like epilepsy and is not indicated for preeclampsia. Furosemide (Choice C) is a diuretic used to manage fluid retention but is not the drug of choice for treating preeclampsia.

2. A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:

• A. Prevent eye infection.
• B. Dilate the pupil so the red reflex can be visualized.
• C. Clear the infant's vision.
• D. Prevent herpes infection.

Correct answer: A

Rationale: The correct answer is A: Prevent eye infection. Eye ointment, usually containing erythromycin, is applied to prevent neonatal conjunctivitis, which can be caused by bacteria present in the birth canal. It is not used to dilate the pupil, clear the infant's vision, or prevent herpes infection.

3. 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.

4. The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?

• A. Palpate the client’s bladder.
• B. Check the pH of the vaginal fluid.
• C. Review the fetal heart rate pattern.
• D. Determine cervical dilation.

Correct answer: D

Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications. While checking the client's bladder may be important to ensure it's not distended, determining cervical dilation takes precedence in this scenario. Checking the pH of the vaginal fluid is not relevant in this situation, and reviewing the fetal heart rate pattern, although important, is not the first action to take when the client expresses the need to go to the bathroom.

5. When can a woman who thinks she may be pregnant use a home pregnancy test to diagnose pregnancy?

• A. A home pregnancy test can be used right after your first missed period.
• B. These tests are most accurate after you have missed your second period.
• C. Home pregnancy tests often give false positives and should not be trusted.
• D. The test can provide accurate information when used right after ovulation.

Correct answer: A

Rationale: The correct answer is A. Home pregnancy tests detect hCG, a hormone produced during pregnancy, and are most accurate after the first missed period when hCG levels are higher. Testing too early may result in a false negative. Waiting until after the first missed period increases the reliability of the test results. Choice B is incorrect as waiting until after the second missed period is unnecessary and may delay seeking appropriate healthcare. Choice C is incorrect as home pregnancy tests are generally reliable when used correctly. Choice D is incorrect because ovulation occurs before the period, and testing immediately after ovulation may not provide accurate results.

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