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. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

• A. Pain level
• B. Blood pressure
• C. Infusion site
• D. Contraction pattern

Correct answer: D

Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.

3. A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record?

• A. 3-1-2-0-3.
• B. 4-1-2-0-3.
• C. 2-1-2-1-2.
• D. 3-1-1-0-3.

Correct answer: D

Rationale: The correct GTPAL for this client is 3-1-1-0-3. G (Gravida) is 3, indicating a total of 3 pregnancies. T (Term) is 1, representing 1 full-term delivery. P (Preterm) is 1, not 2 as mentioned in the question, as twins count as one pregnancy event. A (Abortions) is 0, and L (Living) is 3, indicating 3 living children (twins count as 1). Therefore, the correct answer is 3-1-1-0-3.

4. A neonate with congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

• A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
• B. Support the parents in their decision regarding the sex assignment of their child
• C. Offer information about ultrasonography and genotyping to determine sex assignment
• D. Explain that corrective surgical procedures consistent with sex assignment can be delayed

Correct answer: B

Rationale: Supporting the parents in their decision regarding the sex assignment of their child is crucial as it respects the parental role in making this important decision and helps provide emotional support during a challenging time. The primary focus should be on helping the parents navigate the complexities and implications of determining the sex assignment for their child with ambiguous genitalia.

5. A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

• A. Wear support stockings.
• B. Reduce salt in her diet.
• C. Move about every hour.
• D. Avoid constrictive clothing.

Correct answer: C

Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.

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