Nursing Elites

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?

• A. Speak loudly to the client
• B. Use written communication to assist with communication
• C. Avoid eye contact while speaking
• D. Use sign language without an interpreter

Correct answer: B

Rationale: The correct action for the nurse to take when assessing a client with hearing loss is to use written communication. This method helps ensure effective communication and that the client understands the information being conveyed. Speaking loudly may not be helpful and can be perceived as rude. Avoiding eye contact can hinder communication and appear disrespectful. Using sign language without an interpreter may not be appropriate if the client does not understand sign language.

3. A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. If my partner is Rh-negative, I will not receive the shot.
• B. I will receive the shot after delivery if my baby is Rh-negative.
• C. I should not receive any immunizations for 3 months after the shot.
• D. This shot may be given after birth to protect future pregnancies.

Correct answer: D

Rationale: Choice D is the correct answer because it reflects an understanding of Rh immune globulin administration. Rh immune globulin is given after delivery to prevent sensitization in future pregnancies, particularly if the baby is Rh-positive. Choice A is incorrect because Rh-negative partners do not affect the need for Rh immune globulin. Choice B is incorrect as Rh immune globulin is given if the baby is Rh-positive, not Rh-negative. Choice C is incorrect; there is no requirement to avoid immunizations after receiving Rh immune globulin.

4. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?

• A. Level of consciousness
• B. Deep tendon reflexes
• C. Blood pressure
• D. Urinary output

Correct answer: C

Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.

5. A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?

• A. Abruptio placentae
• B. Hydatidiform mole
• C. Preterm labor
• D. Placenta previa

Correct answer: A

Rationale: Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use suggest abruptio placentae, where the placenta detaches from the uterus prematurely, posing serious risks to both mother and fetus. Hydatidiform mole is characterized by abnormal trophoblastic tissue growth, not continuous pain and bleeding. Preterm labor is premature contractions leading to birth before 37 weeks gestation. Placenta previa involves the placenta partially or completely covering the cervix, presenting with painless vaginal bleeding.

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