Nursing Elites

1. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?

• A. Alert the neonatal team and prepare for neonatal resuscitation
• B. Notify the healthcare provider from the client’s bedside
• C. Obtain written consent for an emergency cesarean section
• D. Draw a blood sample for stat hemoglobin and hematocrit

Correct answer: B

Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.

2. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

• A. Turn off the oxytocin infusion.
• B. Reposition the fetal monitor transducers.
• C. Decrease the rate of the oxytocin infusion.
• D. Alert the charge nurse about the patient's condition.

Correct answer: A

Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.

3. The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?

• A. Provide a quiet environment with subdued lighting.
• B. Have calcium gluconate immediately available.
• C. Assess deep tendon reflexes (DTRs) every 4 hours.
• D. Insert a Foley catheter with a urimeter to monitor hourly output.

Correct answer: B

Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects. Providing a quiet environment with subdued lighting may be beneficial for the client's comfort but is not the highest priority in this situation. Assessing deep tendon reflexes every 4 hours is important when administering magnesium sulfate, but it is not the highest priority compared to having calcium gluconate available. Inserting a Foley catheter with a urimeter to monitor hourly output is not the highest priority when preparing to administer magnesium sulfate in this scenario.

4. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?

• A. Drowsiness and bradycardia.
• B. Depressed reflexes and increased respirations.
• C. Tachycardia and a feeling of nervousness.
• D. A flushed, warm feeling and a dry mouth.

Correct answer: C

Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.

5. After two miscarriages, a client is instructed to increase her daily intake of foods that include folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

• A. Strawberries.
• B. Yogurt.
• C. Collard greens.
• D. Whole milk.

Correct answer: C

Rationale: Collard greens are a good source of folic acid, which is important for preventing neural tube defects, especially in clients with a history of miscarriages. Since the client does not like green leafy vegetables, collard greens could be suggested as an alternative source of folic acid. Yogurt and whole milk do not contain significant amounts of folic acid, and while strawberries are a healthy choice, they are not a high source of folic acid compared to collard greens.

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