Nursing Elites

1. Why is a client with gestational diabetes being scheduled for an amniocentesis when the fetus has an estimated weight of eight pounds (3629 grams) at 36 weeks gestation? What information is the amniocentesis seeking to obtain?

• A. Presence of a neural tube defect.
• B. Chromosomal abnormalities.
• C. Gender of the fetus.
• D. Fetal lung maturity.

Correct answer: D

Rationale: An amniocentesis in this scenario is most likely being performed to assess fetal lung maturity. This is necessary when considering early delivery due to macrosomia (large fetal size), which is a common concern in gestational diabetes. Evaluating fetal lung maturity is crucial to determine if the fetus's lungs are developed enough to support breathing independently outside the womb. The presence of a neural tube defect and chromosomal abnormalities are not typically assessed through amniocentesis in this situation, and determining the gender of the fetus is not the primary purpose of the procedure here.

2. A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What should the nurse do first?

• A. Push the call light for help
• B. Inspect the client's perineum
• C. Notify a healthcare provider
• D. Turn on the infant warmer

Correct answer: B

Rationale: Inspecting the client's perineum immediately is necessary to assess if the baby is being delivered, which would require urgent action. Pushing the call light for help (Choice A) may delay the assessment and immediate action needed. Notifying a healthcare provider (Choice C) might cause further delays, as the situation requires urgent attention. Turning on the infant warmer (Choice D) is not the priority; ensuring safe delivery and assessment of the baby's condition come first.

3. A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

• A. Obtain a blood sample for a serum glucose level
• B. Feed the newborn immediately
• C. Administer 50 mL of dextrose solution IV
• D. Reassess the blood glucose level prior to the next feeding

Correct answer: D

Rationale: A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn. Reassessing the blood glucose level prior to the next feeding ensures ongoing monitoring without unnecessary intervention. Obtaining a blood sample for a serum glucose level (Choice A) is not necessary as the initial reading is normal. Feeding the newborn immediately (Choice B) may not be indicated and could lead to unnecessary interventions. Administering dextrose solution IV (Choice C) is not warranted as the glucose level is within the normal range and does not require immediate correction.

4. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

• A. Allow liberal family visitation
• B. Keep an airway at the bedside
• C. Assess temperature every hour
• D. Monitor blood pressure, pulse, and respiration every 4 hours

Correct answer: B

Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.

5. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

• A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
• B. Risk for altered gas exchange.
• C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
• D. Risk for increased cardiac output, related to the use of antihypertensive drugs.

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.

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