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. A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention?

• A. Ask the client’s mother to call an ambulance for transport to the hospital immediately.
• B. Determine what physical activities the client has performed for the past 24 hours.
• C. Teach the client how to perform pelvic rock exercises and observe for correct feedback.
• D. Ask the client if she has experienced any recent changes in vaginal discharge.

Correct answer: D

Rationale: The priority nursing intervention in this situation is to ask the client if she has experienced any recent changes in vaginal discharge. Changes in vaginal discharge can indicate preterm labor, making it crucial to assess promptly. This information will help determine if the client needs immediate medical attention and appropriate interventions to prevent preterm birth and ensure the well-being of the mother and the baby. Option A is not the priority as back pain alone does not warrant immediate ambulance transport. Option B is less relevant in this context as the focus should be on immediate concerns related to pregnancy. Option C is not the priority as addressing back pain should come after ruling out urgent pregnancy-related issues.

3. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the client's nursing care plan?

• A. Assess temperature every hour.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations every 4 hours.
• D. Keep an airway at the bedside.

Correct answer: D

Rationale: In the case of eclampsia, the priority intervention is to keep an airway at the bedside. Eclampsia is associated with a high risk of convulsions, and having an airway readily available is crucial for prompt intervention in the event of seizures. Assessing temperature, allowing family visitation, and monitoring vital signs are important aspects of care but ensuring airway patency takes precedence in this situation to manage potential complications and ensure the client's safety.

4. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

• A. Pain level
• B. Blood pressure
• C. Infusion site
• D. Contraction pattern

Correct answer: D

Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.

5. A child with ADHD needs help with homework. What should the nurse encourage the parents to do?

• A. Encourage the parents to help the child with homework.
• B. Do the homework for the child.
• C. Set a regular homework schedule.
• D. Provide a quiet environment for homework.

Correct answer: A

Rationale: Encouraging parents to help the child with homework is the most appropriate course of action. By assisting the child, parents can provide necessary support and guidance without taking over the task entirely. This approach fosters independence and helps the child develop academic skills. Option B, doing the homework for the child, is counterproductive as it does not empower the child to learn and grow independently. Option C, setting a regular homework schedule, is important but does not address the immediate need for assistance. Option D, providing a quiet environment for homework, is helpful but does not directly involve parents in supporting the child's academic progress.

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