Nursing Elites

1. A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

• A. Support the infant as it emerges.
• B. Review prenatal laboratory results.
• C. Obtain fetal heart tones.
• D. Apply suprapubic pressure.

Correct answer: A

Rationale: When the fetal head is visible at the perineum, the priority is to support the infant's birth to prevent injury. Providing support as the infant emerges helps ensure a safe delivery process and reduces the risk of complications associated with rapid or uncontrolled birth.

2. The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?

• A. Provide a quiet environment with subdued lighting.
• B. Have calcium gluconate immediately available.
• C. Assess deep tendon reflexes (DTRs) every 4 hours.
• D. Insert a Foley catheter with a urimeter to monitor hourly output.

Correct answer: B

Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects. Providing a quiet environment with subdued lighting may be beneficial for the client's comfort but is not the highest priority in this situation. Assessing deep tendon reflexes every 4 hours is important when administering magnesium sulfate, but it is not the highest priority compared to having calcium gluconate available. Inserting a Foley catheter with a urimeter to monitor hourly output is not the highest priority when preparing to administer magnesium sulfate in this scenario.

3. A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn?

• A. Length of labor and method of delivery.
• B. Infant's condition at birth and treatment received.
• C. Feeding method chosen by the parents.
• D. History of drugs given to the mother during labor.

Correct answer: B

Rationale: When a full-term infant is transferred to the nursery, the most crucial information for the LPN/LVN to receive for immediate care planning is the infant's condition at birth and any treatments received. This data helps in determining the initial care needs and monitoring requirements for the newborn. Choices A, C, and D are not as critical as the infant's condition at birth and treatment received. The length of labor and method of delivery may provide background information but may not be as essential for immediate care planning. The feeding method chosen by the parents and the history of drugs given to the mother during labor are important but do not take precedence over knowing the infant's condition and treatment received.

4. A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

• A. 4+ reflexes
• B. Urinary output of 50 ml per hour
• C. A decrease in respiratory rate from 24 to 16
• D. A decreased body temperature

Correct answer: C

Rationale: A decrease in respiratory rate from 24 to 16 indicates that magnesium sulfate is effectively reducing central nervous system irritability, a desired therapeutic effect. This decrease in respiratory rate signifies that the drug has reached a therapeutic level to control symptoms of severe pregnancy-induced hypertension. Choices A, B, and D are incorrect because 4+ reflexes, urinary output, and body temperature are not direct indicators of achieving a therapeutic level of magnesium sulfate for controlling PIH symptoms.

5. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

• A. Slowly increasing urinary output over the last week.
• B. Respiratory rate changes from the 40s to the 60s.
• C. Changes in apical heart rate from the 180s to the 140s.
• D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.

Correct answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.

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