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. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as

• A. a cephalhematoma, caused by birth trauma and may last up to 8 weeks.
• B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications.
• C. molding, caused by pressure during labor and will disappear within 2 to 3 days.
• D. a subdural hematoma, which can result in lifelong damage.

Correct answer: A

Rationale: Cephalhematoma is the accumulation of blood between the periosteum and skull, often due to birth trauma, and typically resolves within weeks. It is a common finding in newborns and is not usually a cause for concern as it gradually resolves without specific treatment. Subarachnoid hematoma and subdural hematoma are different conditions that present with distinct characteristics and require different management strategies. Therefore, the correct answer is A. Subarachnoid hematoma is typically found in the subarachnoid space and requires immediate intervention, not just observation like cephalhematoma. Molding refers to the shaping of the fetal head during passage through the birth canal and is a temporary change, not a collection of blood like in cephalhematoma. Subdural hematoma is located beneath the dura mater and is associated with significant complications, unlike the self-limiting nature of cephalhematoma.

3. 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.

4. The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?

• A. Tell the mother to follow the iron drops with infant formula instead of orange juice.
• B. Suggest placing the iron drops in the orange juice and then feeding the infant.
• C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
• D. Give the mother positive feedback about the way she administered the medication.

Correct answer: D

Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver. Choices A, B, and C are incorrect because they do not align with the beneficial practice of administering iron drops with orange juice, which enhances iron absorption. Changing the method of administration based on incorrect assumptions or instructing to withhold feeding after giving iron drops is unnecessary and not evidence-based.

5. The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?

• A. Inspect the perineal pad.
• B. Encourage voiding.
• C. Monitor vital signs.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: A boggy uterus that is displaced above and to the right of the umbilicus may indicate a full bladder, which can impede uterine contraction and lead to hemorrhage. Encouraging the client to void helps relieve pressure on the uterus, promoting better contraction and preventing postpartum hemorrhage.

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