Nursing Elites

1. The healthcare provider is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the healthcare provider withhold the drug?

• A. Respiratory rate of 22 breaths/min
• B. A large amount of lochia rubra
• C. Blood pressure 149/90
• D. Positive Homan’s sign

Correct answer: C

Rationale: A blood pressure of 149/90 is an indication to withhold Methergine due to its potential to further increase blood pressure. Methergine is a medication that can cause vasoconstriction, leading to elevated blood pressure. In this case, administering Methergine could exacerbate the elevated blood pressure, posing a risk to the patient. Therefore, it is crucial to withhold the medication in the presence of hypertension to prevent adverse effects. The other options are not directly related to the administration of Methergine. A respiratory rate of 22 breaths/min is within the normal range. A large amount of lochia rubra may indicate normal postpartum bleeding. A positive Homan’s sign is associated with deep vein thrombosis, which is not a contraindication for administering Methergine.

2. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?

• A. The thyroxine level is low because the TSH level is high.
• B. High thyroxine levels do not normally occur in breastfeeding infants.
• C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
• D. The TSH is high because of the low production of T4 by the thyroid.

Correct answer: D

Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.

3. What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?

• A. Administer prescribed IV solution.
• B. Give oral rehydration solution.
• C. Encourage small, frequent meals.
• D. Offer ginger tea to reduce nausea.

Correct answer: A

Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.

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. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?

• A. Measure the infant’s head-to-heel length
• B. Observe the infant for sunsetting eyes
• C. Palpate the anterior fontanel for tension and bulging
• D. Plot the measurement on the infant’s growth chart

Correct answer: C

Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.

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