Nursing Elites

1. A client at 37 weeks of gestation with placenta previa asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

• A. There is an increased risk of introducing infection.
• B. This could initiate preterm labor.
• C. This could result in profound bleeding.
• D. There is an increased risk of rupture of the membranes.

Correct answer: C

Rationale: Performing an internal examination in a client with placenta previa can lead to significant bleeding due to the proximity of the placenta to the cervical os. This bleeding can be severe and potentially life-threatening. Therefore, it is crucial to avoid any unnecessary manipulation that could disrupt the delicate balance and lead to hemorrhage.

2. A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?

• A. HCO3- 30 mEq/L
• B. PaCO2 50 mm Hg
• C. pH 7.45
• D. Potassium 3.3 mEq/L

Correct answer: B

Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.

3. A newborn's mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

• A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months
• B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen
• C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth
• D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Correct answer: C

Rationale: In the scenario where a newborn's mother is positive for hepatitis B surface antigen, the infant should receive both hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. This is crucial to provide passive and active immunity against the Hepatitis B virus. Hepatitis B immune globulin provides immediate protection by giving passive immunity, while the vaccine stimulates active immunity in the infant. Administering both within 12 hours of birth is important to prevent vertical transmission of the virus.

4. When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: A

Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.

5. A healthcare provider is preparing to administer an injection of Rho (D) immunoglobulin. The provider should understand that the purpose of this injection is to prevent which of the following newborn complications?

• A. Hydrops fetalis
• B. Hypobilirubinemia
• C. Biliary atresia
• D. Transient clotting difficulties

Correct answer: B

Rationale: Rho (D) immunoglobulin is given to Rh-negative individuals to prevent hemolytic disease of the newborn (HDN) caused by Rh incompatibility between the mother and the fetus. If an Rh-negative mother carries an Rh-positive fetus, there is a risk of sensitization during pregnancy or childbirth. Sensitization can lead to the production of antibodies that may attack Rh-positive red blood cells in future pregnancies, potentially causing severe hemolytic disease in the newborn, including complications like hydrops fetalis. Hydrops fetalis is a condition characterized by severe edema and fetal organ enlargement due to severe anemia and heart failure in the fetus.

Similar Questions