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. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

3. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

• A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
• B. Growth and development have been abnormal since birth.
• C. Muscular strength can be regained with physical exercise and therapy.
• D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.

Correct answer: A

Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.

4. 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 this client’s nursing care plan?

• A. Keep airway equipment at the bedside.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations q4h.
• D. Assess temperature q1h.

Correct answer: A

Rationale: In a client with eclampsia, the priority intervention is to keep airway equipment at the bedside to manage potential convulsions effectively. This proactive measure is essential to ensure rapid response and intervention in case of convulsions, which can occur in clients with eclampsia.

5. When counseling a couple seeking information about conceiving, the LPN/LVN should know that ovulation usually occurs

• A. two weeks before menstruation.
• B. immediately after menstruation.
• C. immediately before menstruation.
• D. three weeks before menstruation.

Correct answer: A

Rationale: Ovulation typically occurs about 14 days before the start of the next menstrual period. This timing allows for the released egg to travel down the fallopian tube where it may be fertilized by sperm, leading to conception. Understanding the timing of ovulation is crucial for couples trying to conceive to increase their chances of success.

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