Nursing Elites

1. What action should be implemented when preparing to measure the fundal height of a pregnant client?

• A. Have the client empty her bladder.
• B. Request the client lie on her left side.
• C. Perform Leopold's maneuvers first.
• D. Give the client some cold juice to drink.

Correct answer: A

Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.

2. The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?

• A. Reduce activity level and notify the healthcare provider.
• B. Go to bed and assume a knee-chest position.
• C. Massage the uterus and go to the emergency room.
• D. Do not worry as this is a normal occurrence.

Correct answer: A

Rationale: If the client experiences a return to red bleeding after transitioning to pink and white, it may indicate possible complications like hemorrhage or retained placental fragments. Instructing the client to reduce activity level and promptly notify the healthcare provider is crucial for timely evaluation and management of these potentially serious postpartum complications. Choice B is incorrect as assuming a knee-chest position is not the appropriate action for red bleeding postpartum. Choice C is incorrect as massaging the uterus without professional assessment can be dangerous. Choice D is incorrect because red bleeding after transitioning is not normal and should be evaluated promptly.

3. The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

• A. Elicit a positive scarf sign on the affected side.
• B. Observe for an asymmetrical Moro (startle) reflex.
• C. Watch for swelling of fingers on the affected side.
• D. Note paralysis of the affected extremity and muscles.

Correct answer: B

Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.

4. A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

• A. Support the infant as it emerges.
• B. Review prenatal laboratory results.
• C. Obtain fetal heart tones.
• D. Apply suprapubic pressure.

Correct answer: A

Rationale: When the fetal head is visible at the perineum, the priority is to support the infant's birth to prevent injury. Providing support as the infant emerges helps ensure a safe delivery process and reduces the risk of complications associated with rapid or uncontrolled birth.

5. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

• A. Weight gain.
• B. Reduction of fever.
• C. Improved caloric intake.
• D. Reduction of edema.

Correct answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

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