Nursing Elites

1. The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

• A. Assess cervical dilation.
• B. Change the client's position.
• C. Administer oxygen via facemask.
• D. Turn off the oxytocin infusion.

Correct answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

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

• A. Keep airway equipment at the bedside.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations q4h.
• D. Assess temperature q1h.

Correct answer: A

Rationale: In a client with eclampsia, the priority intervention is to keep airway equipment at the bedside to manage potential convulsions effectively. This proactive measure is essential to ensure rapid response and intervention in case of convulsions, which can occur in clients with eclampsia.

3. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

• A. Encourage the mother to provide total care for her infant.
• B. Provide privacy so the mother can develop a relationship with the infant.
• C. Encourage the father to provide most of the infant's care during hospitalization.
• D. Meet the mother's physical needs and demonstrate warmth toward the infant.

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

4. During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?

• A. Obtain blood and urine for prenatal screens.
• B. Schedule prenatal visits to occur monthly.
• C. Explain common complications of pregnancy.
• D. Obtain baseline blood pressure and weight.

Correct answer: A

Rationale: Obtaining blood and urine for prenatal screens is crucial in identifying any potential infections or conditions that may require monitoring throughout the pregnancy. Screening for infections such as syphilis is essential to ensure appropriate management and prevent adverse outcomes. This action helps in early detection and timely intervention, promoting the health and well-being of both the mother and the developing fetus. The other options, while important during prenatal care, are not as critical as obtaining prenatal screens to assess for any existing infections that could impact the pregnancy.

5. A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

• A. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
• B. Discuss options for intrauterine surgical correction of congenital defects.
• C. Reassure the client that the AFP results are likely to be a false reading.
• D. Explain that a sonogram should be scheduled for definitive results.

Correct answer: D

Rationale: An elevated alpha-fetoprotein (AFP) level in a pregnant client can indicate potential congenital anomalies in the fetus. A follow-up sonogram is necessary to provide definitive results and further evaluate the fetus for any possible abnormalities. Therefore, it is essential for the nurse to explain to the client that scheduling a sonogram is the next appropriate step to assess the fetal well-being and address any concerns regarding the elevated AFP level. Choices A, B, and C are incorrect because a repeat AFP test alone, discussing surgical correction of defects, or assuming the results are false without further evaluation are not appropriate responses when dealing with a potentially serious issue like elevated AFP levels in pregnancy.

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