Nursing Elites

1. When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

• A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
• B. Count the movements once daily, for one hour, before breakfast.
• C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
• D. Exercise for 15 minutes before starting the counting to help increase fetal movement.

Correct answer: A

Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.

2. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit
• B. Administer the scheduled dose
• C. Calculate the safe dose range
• D. Review the serum digoxin level

Correct answer: B

Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.

3. The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?

• A. Heat loss.
• B. Fluid balance.
• C. Bleeding tendencies.
• D. Hypoglycemia.

Correct answer: A

Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.

4. The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client?

• A. Clonidine hydrochloride
• B. Carbamazepine
• C. Furosemide
• D. Magnesium sulfate

Correct answer: D

Rationale: In the scenario presented, the client is exhibiting signs and symptoms of severe preeclampsia, including hypertension, proteinuria, facial and hand swelling, visual disturbances, and a severe headache. The medication of choice for preventing seizures in preeclampsia is magnesium sulfate. This drug helps to prevent and control seizures in clients with preeclampsia, making it the most appropriate option for this client. Clonidine hydrochloride (Choice A) is an antihypertensive medication used for managing hypertension but is not the first-line treatment for preeclampsia. Carbamazepine (Choice B) is an anticonvulsant used for seizure disorders like epilepsy and is not indicated for preeclampsia. Furosemide (Choice C) is a diuretic used to manage fluid retention but is not the drug of choice for treating preeclampsia.

5. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?

• A. Flaring of the nares.
• B. Shallow and irregular respirations.
• C. Respiratory rate of 50 breaths per minute.
• D. Abdominal breathing with synchronous chest movement.

Correct answer: A

Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.

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