Nursing Elites

1. A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?

• A. Using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and STIs.
• B. A diaphragm should be removed 2 hours after intercourse.
• C. Oral contraceptives can worsen a case of acne.
• D. A contraceptive patch is replaced once a month.

Correct answer: A

Rationale: The correct answer is A because using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and sexually transmitted infections (STIs). This statement demonstrates the client's understanding of the importance of proper condom use to maximize protection. Choice B is incorrect because a diaphragm should be left in place for at least 6 hours after intercourse to ensure contraceptive effectiveness. Choice C is incorrect as oral contraceptives are known to improve acne in some cases. Choice D is incorrect because a contraceptive patch is typically replaced weekly, not monthly.

2. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?

• A. 1+ pitting sacral edema
• B. 3+ protein in the urine
• C. Blood pressure 148/98 mm Hg
• D. Deep tendon reflexes of +1

Correct answer: D

Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.

3. A client who is pregnant is scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply)

• A. Decreased fetal movement
• B. Intrauterine growth restriction (IUGR)
• C. Postmaturity
• D. All of the Above

Correct answer: D

Rationale: A contraction stress test (CST) is performed to assess how the fetus responds to the stress of contractions. Indications for this test include decreased fetal movement, intrauterine growth restriction (IUGR), and postmaturity. These conditions may warrant the need for a CST to evaluate fetal well-being and determine appropriate management. Therefore, all of the above options are correct indications for a contraction stress test. Options A, B, and C are incorrect because they are all valid reasons for performing a CST in a pregnant client.

4. A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?

• A. Confirm the newborn's identification.
• B. Verify the newborn's identification.
• C. Administer vitamin K to the newborn.
• D. Determine obstetrical risk factors.

Correct answer: B

Rationale: When a newborn is transferred to the nursery, the first action the nurse should take is to verify the newborn's identification. This step is crucial for ensuring the correct care is provided to the right newborn, promoting patient safety and preventing errors. Administering vitamin K (Choice C) is important but should not be the first action. Determining obstetrical risk factors (Choice D) is not the priority when the newborn is transferred to the nursery. Confirming (Choice A) and verifying (Choice B) have similar meanings, but 'verify' is a more appropriate term in this context.

5. A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?

• A. Vastus lateralis
• B. Ventrogluteal
• C. Dorsogluteal
• D. Deltoid

Correct answer: A

Rationale: Vitamin K is typically administered in the vastus lateralis muscle of a newborn to prevent bleeding disorders. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and accessibility, allowing for easy and safe administration. The ventrogluteal and dorsogluteal sites are more commonly used in adults due to better muscle mass and less risk of injury to nearby structures. The deltoid muscle is typically used for older children and adults for IM injections, as it is a well-developed muscle suitable for injections in these populations.

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