Nursing Elites

1. What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?

• A. Maternal blood pressure.
• B. Level of pain sensation.
• C. Station of presenting part.
• D. Variability of fetal heart rate.

Correct answer: A

Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia. The other options, such as assessing the level of pain sensation, station of presenting part, and variability of fetal heart rate, are important in obstetric care but are not as critical as monitoring maternal blood pressure to prevent complications related to epidural anesthesia administration.

2. The healthcare provider is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the healthcare provider is administering this medication?

• A. Prevent hemorrhagic disorders.
• B. Help an immature liver.
• C. Improve insufficient dietary intake.
• D. Stimulate the immune system.

Correct answer: A

Rationale: The correct answer is A: 'Prevent hemorrhagic disorders.' Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease by promoting blood clotting. Newborns are born with low levels of vitamin K, which is essential for blood clotting, hence the administration to prevent hemorrhagic disorders. Choice B is incorrect because phytonadione is not given to help an immature liver but to supply vitamin K. Choice C is incorrect as phytonadione is not administered to improve dietary intake but to provide essential vitamin K. Choice D is incorrect as phytonadione does not stimulate the immune system but helps with blood clotting.

3. While preparing a 10-year-old with a lacerated forehead for suturing, the nurse notices both parents and a 12-year-old sibling at the child’s bedside. Which instruction best supports the family's involvement?

• A. While waiting for the healthcare provider, only one visitor may stay with the child.
• B. All of you should leave while the healthcare provider sutures the child’s forehead.
• C. It is best if the sibling goes to the waiting room until the suturing is completed.
• D. Please decide who will stay when the healthcare provider begins suturing.

Correct answer: D

Rationale: Involving the family by letting them decide who will stay during the suturing process promotes family engagement and comfort, ensuring the presence of a familiar person for the child during the procedure.

4. The LPN/LVN should explain to a 30-year-old gravida client that alpha fetoprotein testing is recommended for which purpose?

• A. Detect cardiovascular disorders.
• B. Screen for neural tube defects.
• C. Monitor placental functioning.
• D. Assess for maternal pre-eclampsia.

Correct answer: B

Rationale: The correct answer is B: Screen for neural tube defects. Alpha fetoprotein testing is primarily used to screen for neural tube defects and other fetal abnormalities. It is not used to detect cardiovascular disorders, monitor placental functioning, or assess for maternal pre-eclampsia.

5. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

• A. Patellar reflex 4+
• B. Blood pressure 158/80
• C. Four-hour urine output 240 ml
• D. Respirations 12/minute

Correct answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

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