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 healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

• A. A gravida 6, para 5 who is 38 years of age and in early labor.
• B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
• C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
• D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.

Correct answer: D

Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.

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. The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

• A. Assess cervical dilation.
• B. Change the client's position.
• C. Administer oxygen via facemask.
• D. Turn off the oxytocin infusion.

Correct answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

5. A newborn with a yellow abdomen and chest is being assessed. What should be the nurse's initial action?

• A. Assess bilirubin level.
• B. Administer phototherapy.
• C. Encourage feeding to help reduce bilirubin levels.
• D. Perform a bilirubin test every hour.

Correct answer: A

Rationale: The correct action when assessing a newborn with a yellow abdomen and chest is to initially assess the bilirubin level. This helps determine the severity of jaundice in the newborn. Administering phototherapy (choice B) is a treatment intervention that follows the assessment. Encouraging feeding (choice C) can help with bilirubin excretion but is not the initial assessment. Performing a bilirubin test every hour (choice D) may not be necessary initially and could lead to unnecessary interventions.

Similar Questions