Nursing Elites

1. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?

• A. CO2 combining power
• B. Calcium
• C. Sodium
• D. Chloride

Correct answer: B

Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.

2. The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?

• A. Palpate the client’s bladder.
• B. Check the pH of the vaginal fluid.
• C. Review the fetal heart rate pattern.
• D. Determine cervical dilation.

Correct answer: D

Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications. While checking the client's bladder may be important to ensure it's not distended, determining cervical dilation takes precedence in this scenario. Checking the pH of the vaginal fluid is not relevant in this situation, and reviewing the fetal heart rate pattern, although important, is not the first action to take when the client expresses the need to go to the bathroom.

3. At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?

• A. Color and consistency of fluid.
• B. Estimated amount of fluid.
• C. Any odor noted at the rupture of membranes.
• D. Time of membrane rupture.

Correct answer: A

Rationale: Assessing the color and consistency of amniotic fluid is crucial as it can indicate the presence of meconium, which suggests potential fetal distress. This information guides the need for further assessments and interventions to ensure the well-being of the mother and fetus. Estimating the amount of fluid is not as critical as determining the color and consistency to identify fetal distress. While noting any odor is important, it is secondary to assessing the fluid itself. Knowing the time of membrane rupture is helpful but not as crucial as evaluating the characteristics of the amniotic fluid.

4. The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?

• A. 150 mL/hour
• B. 250 mL/hour
• C. 50 mL/hour
• D. 275 mL/hour

Correct answer: A

Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. The IV bag contains 20 grams of magnesium sulfate in 500 mL of solution, which means there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. Choice B, 250 mL/hour, is incorrect because it miscalculates the amount of magnesium sulfate infused per hour. Choice C, 50 mL/hour, is incorrect as it is too slow to deliver the required dose in the specified time frame. Choice D, 275 mL/hour, is incorrect as it overestimates the infusion rate and would deliver the dose too quickly.

5. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

• A. Encourage the mother to provide total care for her infant.
• B. Provide privacy so the mother can develop a relationship with the infant.
• C. Encourage the father to provide most of the infant's care during hospitalization.
• D. Meet the mother's physical needs and demonstrate warmth toward the infant.

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

Similar Questions