Nursing Elites

1. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following comp

• A. Placenta previa
• B. Prolapsed cord
• C. Incompetent cervix
• D. Abruptio placentae

Correct answer: D

Rationale:

2. A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

• A. Elevate the head of the bed to at least 30�.
• B. Apply restraints if the client becomes agitated.
• C. Administer pantoprazole as prescribed.
• D. Reposition the endotracheal tube to the opposite side of the mouth daily.

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30� helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.

3. A client at 22 weeks of gestation with uncontrolled gestational diabetes mellitus may require medication. Which of the following medications would the provider likely prescribe?

• A. Acarbose
• B. Repaglinide
• C. Glyburide
• D. Glipizide

Correct answer: C

Rationale: Glyburide is commonly prescribed for gestational diabetes mellitus when diet and exercise are insufficient to control blood sugar levels. It is considered safe and effective during pregnancy, making it a suitable choice for managing diabetes in pregnant individuals. Acarbose, Repaglinide, and Glipizide are not typically recommended for use in pregnancy due to potential risks to the fetus.

4. A client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?

• A. The client is carrying more than one fetus
• B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid
• C. An excessive amount of amniotic fluid is present
• D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor

Correct answer: C

Rationale: Polyhydramnios refers to the presence of an excessive amount of amniotic fluid around the fetus. This condition can result from various causes, such as maternal diabetes, fetal anomalies, or genetic disorders. It can lead to complications during pregnancy and delivery, such as preterm labor, placental abruption, or fetal malpresentation. Understanding this diagnosis is crucial for providing appropriate care and monitoring to ensure the best outcomes for both the mother and the fetus.

5. During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?

• A. Tachycardia
• B. Absence of clonus
• C. Polyuria
• D. Report of headache

Correct answer: D

Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.

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