Nursing Elites

1. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

• A. Allow liberal family visitation
• B. Keep an airway at the bedside
• C. Assess temperature every hour
• D. Monitor blood pressure, pulse, and respiration every 4 hours

Correct answer: B

Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.

2. According to a survey by Adhikari and Liu in the year 2013, at birth, women have:

• A. close to 100,000 ova.
• B. around 300,000 to 400,000 ova.
• C. around 100 to 200 ova.
• D. only 500 ova.

Correct answer: B

Rationale: Women are born with approximately 300,000 to 400,000 ova, which gradually decrease in number as they age. Choice A ('close to 100,000 ova.') is incorrect as the actual number is much higher. Choice C ('around 100 to 200 ova.') is incorrect as it underestimates the quantity significantly. Choice D ('only 500 ova.') is incorrect as it greatly underestimates the number of ova present at birth.

3. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?

• A. Caput succedaneum
• B. Hydrocephalus
• C. Cephalhematoma
• D. Microcephaly

Correct answer: C

Rationale: The correct answer is Cephalhematoma. Cephalhematoma is a collection of blood between the skull bone and periosteum that does not cross the suture line. It often occurs due to birth trauma, such as forceps delivery, leading to localized swelling. Caput succedaneum (Choice A) is diffuse swelling of the scalp that may cross suture lines and is typically present at birth. Hydrocephalus (Choice B) is an abnormal accumulation of cerebrospinal fluid within the brain's ventricles. Microcephaly (Choice D) is a condition characterized by a smaller than average head size and may be present at birth or develop later in infancy.

4. Is Duchenne muscular dystrophy a sex-linked abnormality?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: A

Rationale: The correct answer is A: TRUE. Duchenne muscular dystrophy is an X-linked recessive disorder, primarily affecting males. This is due to the inheritance of the mutated gene on the X chromosome. Choices B, C, and D are incorrect because Duchenne muscular dystrophy is specifically classified as a sex-linked disorder affecting males due to the inheritance pattern.

5. A client with preeclampsia is receiving magnesium sulfate by continuous IV infusion. Which finding should the nurse report to the provider?

• A. Blood pressure 148/94 mm Hg
• B. Respiratory rate 14/min
• C. Urinary output 20 mL/hr
• D. 2+ deep tendon reflexes

Correct answer: C

Rationale: In a client with preeclampsia receiving magnesium sulfate, a urinary output of 20 mL/hr is a concerning finding as it may indicate renal impairment or magnesium toxicity. Adequate urinary output is crucial for eliminating excess magnesium and preventing toxicity. The nurse should report this finding to the provider for further evaluation. A blood pressure of 148/94 mm Hg is elevated but expected in a client with preeclampsia. A respiratory rate of 14/min is within the normal range. 2+ deep tendon reflexes are a common finding in clients receiving magnesium sulfate and are not a cause for concern unless they progress to hyperreflexia or clonus.

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