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 prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer’s Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump?

• A. 12 mL/hour
• B. 2 mL/hour
• C. 22 mL/hour
• D. 42 mL/hour

Correct answer: A

Rationale: To calculate the infusion rate in mL/hour, first, convert 2 milliunits/minute to milliunits/hour by multiplying by 60 to get 120 milliunits/hour. Then, calculate the mL/hour using the formula: milliunits/hour (120) × total volume (1000 mL) ÷ units in IV solution (10 units) = 1200 mL/hour. Therefore, the nurse should program the infusion pump to deliver 12 mL/hour to provide the prescribed dose of oxytocin. Choice B is incorrect as it does not reflect the correct calculation. Choice C is incorrect as it is not derived from the correct formula. Choice D is incorrect as it is not the result of the accurate calculation based on the provided information.

3. The LPN/LVN should explain to a 30-year-old gravida client that alpha fetoprotein testing is recommended for which purpose?

• A. Detect cardiovascular disorders.
• B. Screen for neural tube defects.
• C. Monitor placental functioning.
• D. Assess for maternal pre-eclampsia.

Correct answer: B

Rationale: The correct answer is B: Screen for neural tube defects. Alpha fetoprotein testing is primarily used to screen for neural tube defects and other fetal abnormalities. It is not used to detect cardiovascular disorders, monitor placental functioning, or assess for maternal pre-eclampsia.

4. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?

• A. Body temperature.
• B. Level of pain.
• C. Time of first void.
• D. Number of vessels in the cord.

Correct answer: D

Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.

5. After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

• A. Wipe away the spit-up and assist the mother with the diaper change.
• B. Sit the newborn upright and burp by rubbing or patting the upper back.
• C. Place the newborn in a position with the head lower than the feet.
• D. Turn the newborn to the side and use bulb suction for the mouth and nares.

Correct answer: B

Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.

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