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 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.

3. During the admission procedure of a 6-year-old, the child states, 'I’m going to have an operation.' Which response is best for the nurse to provide to this child?

• A. Are you scared?
• B. We’re going to do everything we can to take very good care of you.
• C. Tell me what an operation is.
• D. I’m glad your mother told you why you were coming to the hospital.

Correct answer: B

Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.

4. The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?

• A. Litmus paper.
• B. Fetal scalp electrode.
• C. A sterile glove.
• D. Needle and Thread

Correct answer: C

Rationale: For performing an amniotomy, the nurse should have a sterile glove to maintain asepsis and an amniotic hook to rupture the amniotic sac. Litmus paper is not required for this procedure, and a fetal scalp electrode is used for fetal monitoring, not for an amniotomy.

5. The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant’s care?

• A. Blood pressure 76/42 mmHg.
• B. Faint heart murmur.
• C. Respiratory rate of 76 breaths/minute.
• D. Blood glucose 45 mg/dl.

Correct answer: C

Rationale: A high respiratory rate in a newborn is concerning as it may indicate respiratory distress, which requires immediate attention to ensure adequate oxygenation. Monitoring and addressing respiratory issues take precedence over other parameters in the initial assessment of a newborn. The blood pressure, heart murmur, and blood glucose levels are important but not as urgent as addressing potential respiratory distress in a newborn.

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