Nursing Elites

1. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?

• A. Notify the healthcare provider immediately.
• B. Suction the infant's nares, then the oral cavity.
• C. Check the infant's oxygen saturation rate.
• D. Position the infant on the right side.

Correct answer: C

Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.

2. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

• A. Urinary output and fluid intake.
• B. Hemoglobin and hematocrit.
• C. Abdominal contour and bowel sounds.
• D. Heart rate and blood pressure.

Correct answer: D

Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.

3. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?

• A. Decrease the oxytocin infusion rate
• B. Determine current cervical dilation
• C. Request placement of the epidural
• D. Give a bolus of intravenous fluids

Correct answer: D

Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.

4. A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

• A. Wear support stockings.
• B. Reduce salt in her diet.
• C. Move about every hour.
• D. Avoid constrictive clothing.

Correct answer: C

Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.

5. After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

• A. Check the differential, as the WBC count can be normal for this client.
• B. Assess the client's temperature, pulse, and respirations every 4 hours.
• C. Notify the healthcare provider, as this finding may indicate infection.
• D. Assess the client's perineal area for signs of a perineal hematoma.

Correct answer: A

Rationale: In postpartum clients, a white blood cell count of 15,000/mm3 can be within normal limits due to physiological changes that occur after childbirth. Checking the differential count would provide a more detailed analysis of the specific types of white blood cells present, helping to differentiate between normal postpartum changes and potential infection. This action allows the nurse to gather more information before escalating the situation to the healthcare provider or initiating other assessments. Assessing vital signs and the perineal area are important aspects of postpartum care but may not be the priority in this scenario where the white blood cell count can be influenced by normal physiological changes.

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