Nursing Elites

1. When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?

• A. Hgb 12.2 g/dL
• B. Urine ketones present
• C. Alanine aminotransferase 20 IU/L
• D. Blood glucose 114 mg/dL

Correct answer: B

Rationale: The correct answer is B: Urine ketones present. The presence of urine ketones indicates dehydration, which is a common manifestation of hyperemesis gravidarum. Hyperemesis gravidarum is characterized by severe nausea, vomiting, weight loss, and electrolyte imbalances due to dehydration. Monitoring for ketonuria helps assess the degree of dehydration in clients with this condition. Choices A, C, and D are incorrect because hemoglobin level, alanine aminotransferase level, and blood glucose level are not specific manifestations of hyperemesis gravidarum. While these laboratory values may be abnormal in some cases, they are not typically used to diagnose or assess the condition.

2. A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, 'I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device.' The nurse should suspect which of the following?

• A. Missed abortion
• B. Ectopic pregnancy
• C. Severe preeclampsia
• D. Hydatidiform mole

Correct answer: B

Rationale: Ectopic pregnancy should be suspected in clients with abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding, especially if they have an intrauterine device (IUD). In this case, the client's symptoms are classic for ectopic pregnancy, where the fertilized egg implants outside the uterus, commonly in the fallopian tube. Missed abortion (choice A) refers to a nonviable embryo or fetus in the uterus, which is not consistent with the client's presentation. Severe preeclampsia (choice C) is characterized by hypertension and proteinuria, not the symptoms described. Hydatidiform mole (choice D) presents with vaginal bleeding but typically lacks abdominal pain and is not related to the presence of an IUD.

3. A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

• A. Respirations less than 12/min
• B. Urinary output less than 25 mL/hr
• C. Decreased level of consciousness
• D. All of the above

Correct answer: D

Rationale: Signs of magnesium sulfate toxicity include respirations less than 12/min, urinary output less than 25 mL/hr, and decreased level of consciousness. These signs indicate potential overdose of magnesium sulfate and require immediate attention to prevent further complications. Reporting these signs promptly is crucial to ensure the client's safety and well-being. Choice D, 'All of the above,' is the correct answer as all the listed findings are indicative of magnesium sulfate toxicity. Choices A, B, and C individually represent different signs of toxicity, making them incorrect on their own. Therefore, the nurse should be vigilant in identifying and reporting all these signs to prevent adverse outcomes.

4. A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?

• A. Bruising over the buttocks
• B. Hard nodules on the roof of the mouth
• C. Petechiae over the head
• D. Bilateral periauricular papillomas

Correct answer: C

Rationale: When a newborn experiences a tight nuchal cord during delivery, it can lead to petechiae, which are small red or purple spots on the skin caused by bleeding under the skin. These petechiae may appear over the head, face, and neck due to the pressure of the cord. It is essential for the nurse to recognize this as a possible consequence and monitor the newborn for any signs of complications. Bruising over the buttocks (Choice A) is not typically associated with a tight nuchal cord. Hard nodules on the roof of the mouth (Choice B) are more indicative of Epstein pearls or Bohn's nodules, which are considered normal findings in newborns. Bilateral periauricular papillomas (Choice D) are not related to a tight nuchal cord but are seen in congenital syphilis.

5. A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?

• A. Encourage the parents to touch and explore the newborn's features
• B. Limit noise and interruptions in the delivery room
• C. Place the newborn at the client's breast
• D. Position the newborn skin-to-skin on the client's chest

Correct answer: D

Rationale: Positioning the newborn skin-to-skin on the client's chest is the priority action to promote warmth, regulate the newborn's heart rate and breathing, and enhance parent-infant bonding. This method facilitates early bonding, stabilizes the baby's temperature, and encourages breastfeeding initiation. Encouraging parents to touch and explore the newborn's features is important but not the priority at this moment. Limiting noise and interruptions can be beneficial but not as crucial as skin-to-skin contact for bonding. Placing the newborn at the client's breast is essential for breastfeeding but should come after the initial skin-to-skin contact for bonding and temperature regulation.

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