Nursing Elites

1. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?

• A. Administer indomethacin
• B. Insert a second 22-gauge IV catheter.
• C. Insert an indwelling urinary catheter.
• D. Administer oxygen at 4L/min via nasal cannula.

Correct answer: D

Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.

2. A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?

• A. The mother is Rh positive, and the father is Rh negative
• B. The mother is Rh negative, and the father is Rh positive
• C. The mother and the father are both Rh positive
• D. The mother and the father are both Rh negative

Correct answer: B

Rationale: The correct answer is B: 'The mother is Rh negative, and the father is Rh positive.' Hemolytic disease of the newborn occurs when an Rh-negative mother carries an Rh-positive fetus, leading to Rh incompatibility. In this scenario, the mother produces antibodies against the Rh antigen present in the fetus, which can result in hemolysis of the fetal red blood cells. Choices A, C, and D do not describe the Rh incompatibility that leads to hemolytic disease in newborns. Therefore, they are incorrect.

3. In the prenatal record, the nurse should record for the pregnant client who has a 3-year-old child at home, a term birth, a miscarriage at 10 weeks’ gestation, and a set of twins who died within 24 hours:

• A. Gravida 2, para 1.
• B. Gravida 3, para 3.
• C. Gravida 4, para 2.
• D. Gravida 5, para 4.

Correct answer: C

Rationale: The correct answer is C: 'Gravida 4, para 2.' Gravida refers to the total number of pregnancies, including the current one. In this case, the client has been pregnant a total of 4 times, so gravida is 4. Para is the number of pregnancies that have reached viability, which is 2 in this case. The client has had a term birth and a set of twins who died within 24 hours, totaling 2 pregnancies that reached viability. Choices A, B, and D are incorrect because they do not accurately reflect the client's obstetric history based on the information provided.

4. Are babies with fetal alcohol syndrome (FAS) often larger than normal, and so are their brains?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: B

Rationale: The correct answer is B: FALSE. Babies with fetal alcohol syndrome (FAS) are typically smaller than normal, with smaller brains and developmental issues. Choice A is incorrect because babies with FAS are not larger than normal. Choice C is incorrect as it does not accurately reflect the typical characteristics of babies with FAS. Choice D is incorrect as babies with FAS are not always larger than normal.

5. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

• A. Allow liberal family visitation
• B. Keep an airway at the bedside
• C. Assess temperature every hour
• D. Monitor blood pressure, pulse, and respiration every 4 hours

Correct answer: B

Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.

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