Nursing Elites

1. A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?

• A. Use an alternative form of contraception until a new diaphragm is obtained.
• B. After weaning, the diaphragm should be resized.
• C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
• D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.

Correct answer: A

Rationale: The nurse should advise the client to use an alternative form of contraception until a new diaphragm that fits correctly post-pregnancy is obtained. It is essential to ensure proper fit for effective contraception, making it crucial to use an alternative method until the diaphragm is resized.

2. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?

• A. Place the infant in a knee-chest position.
• B. Administer morphine sulfate.
• C. Start intravenous fluids.
• D. Provide 100% oxygen by face mask.

Correct answer: A

Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions. Administering morphine sulfate (choice B) is not the first-line treatment for tetralogy of Fallot crisis. Starting intravenous fluids (choice C) may be necessary but is not the priority in this situation. Providing 100% oxygen by face mask (choice D) may not fully address the underlying issue of decreased systemic vascular resistance that leads to cyanosis in tetralogy of Fallot.

3. Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?

• A. The client's readiness to learn.
• B. The client's educational background.
• C. The order in which the information is presented.
• D. The extent to which the pregnancy was planned.

Correct answer: A

Rationale: The client's readiness to learn is the most critical factor influencing successful teaching of the gravid client. When a client is receptive and motivated to learn, they are more likely to engage with the information provided, leading to better understanding and retention.

4. Upon admission to the prenatal clinic, a 23-year-old woman informs the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What is this client's expected date of delivery (EDD)?

• A. November 22.
• B. November 8.
• C. December 22.
• D. October 22.

Correct answer: A

Rationale: To determine the expected date of delivery (EDD) using Nägele's rule, add 7 days to the first day of the last menstrual period (LMP) which is February 15, resulting in February 22. Then, subtract 3 months from February 22, which gives November 22 as the estimated due date.

5. The nurse is planning care for a 4-year-old girl diagnosed with a developmental disability. What should be the primary focus of treatment for this child?

• A. Teach her social skills.
• B. Assist in preventing further disability.
• C. Ensure her participation in group activities.
• D. Help her achieve her maximum potential.

Correct answer: D

Rationale: The primary focus of treatment for a child diagnosed with a developmental disability should be helping them achieve their maximum potential. This approach aims to optimize the child's physical, emotional, cognitive, and social abilities, focusing on enhancing their overall well-being and quality of life. By supporting the child in reaching their highest level of functioning, caregivers can promote independence, self-esteem, and personal growth, which are essential components of holistic care for individuals with developmental disabilities. Teaching social skills (choice A) is important but is just one aspect of the comprehensive care needed. Preventing further disability (choice B) may not always be entirely achievable, but maximizing potential is a more realistic goal. Ensuring participation in group activities (choice C) is valuable for social development, but the primary focus should be on overall potential and well-being.

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