Nursing Elites

1. A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?

• A. Weigh the baby daily, and if she is gaining weight, she is eating enough.
• B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
• C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry.
• D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.

Correct answer: B

Rationale: The correct answer is B. Adequate voiding is a sign that the baby is receiving enough milk. Pale straw-colored urine 6 to 10 times a day indicates proper hydration and nutrition. This is a reliable indicator of adequate breast milk intake for the infant. Choice A is incorrect because weight gain alone may not always indicate sufficient milk intake. Choice C is incorrect because supplementing with bottle milk can interfere with establishing breastfeeding. Choice D is incorrect as it suggests switching to bottle feeding, which is not necessary if the baby is latching and voiding well.

2. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

• A. Turn off the oxytocin infusion.
• B. Reposition the fetal monitor transducers.
• C. Decrease the rate of the oxytocin infusion.
• D. Alert the charge nurse about the patient's condition.

Correct answer: A

Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.

3. During a prenatal visit, the LPN/LVN discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have

• A. lower Apgar scores.
• B. lower birth weights.
• C. respiratory distress.
• D. a higher rate of congenital anomalies.

Correct answer: B

Rationale: When mothers smoke during pregnancy, it is associated with intrauterine growth restriction, which leads to lower birth weights in infants. Maternal smoking can restrict the flow of oxygen and nutrients to the fetus, affecting its growth and development. This can result in babies being born with lower birth weights, which can have various health implications for the newborn. Choices A, C, and D are incorrect as smoking during pregnancy is primarily linked to intrauterine growth restriction and lower birth weights in infants, rather than lower Apgar scores, respiratory distress, or a higher rate of congenital anomalies.

4. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?

• A. Reduce cerebral edema and lower intracranial pressure
• B. Avert hypotension and septic shock
• C. Prevent cardiac arrhythmias and heart failure
• D. Promote kidney perfusion and normal blood pressure

Correct answer: A

Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.

5. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

• A. 3+ deep tendon reflexes and hyperreflexia.
• B. Periorbital edema, flashing lights, and aura.
• C. Epigastric pain in the third trimester.
• D. Recent decreased urinary output.

Correct answer: A

Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.

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