Nursing Elites

1. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

• A. Monitor the client's blood pressure every hour.
• B. Restrict the total hourly intake to 200 mL.
• C. Monitor the FHR continuously.
• D. Administer protamine sulfate for manifestations of toxicity.

Correct answer: C

Rationale: The correct answer is C. When a client with preeclampsia is receiving magnesium sulfate via continuous IV infusion, it is crucial to monitor the fetal heart rate (FHR) continuously. Magnesium sulfate is given to prevent seizures and is considered a high-alert medication that requires close monitoring, especially of FHR and uterine contractions. Monitoring the client's blood pressure every hour, as in choice A, is important but not as crucial as continuous FHR monitoring. Restricting the total hourly intake to 200 mL, as in choice B, is not a relevant intervention for a client receiving magnesium sulfate. Administering protamine sulfate for manifestations of toxicity, as in choice D, is incorrect as protamine sulfate is not the antidote for magnesium sulfate toxicity.

2. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

• A. Maternal/newborn blood group incompatibility
• B. Absence of vitamin K
• C. Physiologic jaundice
• D. Maternal cocaine abuse

Correct answer: A

Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.

3. A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

• A. Oligohydramnios
• B. Hydramnios
• C. Fetal cord compression
• D. Polyhydramnios

Correct answer: A

Rationale: In this scenario, the correct answer is "Oligohydramnios". Oligohydramnios, which refers to low amniotic fluid volume, may necessitate amnioinfusion to address the deficiency. Fetal cord compression is another indication for amnioinfusion as it can help alleviate pressure on the umbilical cord. Hydramnios or polyhydramnios, conversely, involve an excess of amniotic fluid and do not typically require amnioinfusion. Therefore, choices B, C, and D are incorrect in this context.

4. A woman at 38 weeks of gestation is admitted in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

• A. Recheck the client's temperature in 4 hours.
• B. Administer glucocorticoids intramuscularly.
• C. Assess the odor of the amniotic fluid.
• D. Prepare the client for emergency cesarean section.

Correct answer: C

Rationale: An elevated temperature in a woman with ruptured membranes may indicate infection. Assessing the odor of the amniotic fluid can help determine if chorioamnionitis (an infection of the amniotic fluid) is present. This assessment is crucial to guide further interventions and management of the client's condition. Options A, B, and D are incorrect. Rechecking the client's temperature in 4 hours does not address the immediate concern of potential infection. Administering glucocorticoids intramuscularly is not indicated based solely on an elevated temperature. Preparing the client for an emergency cesarean section is premature and not supported by the information provided.

5. A client in a family planning clinic requests oral contraceptives. Which of the following findings in the client's history should be recognized as contraindications to oral contraceptives? (Select all that apply.)

• A. Cholecystitis
• B. Hypertension
• C. Migraine headaches
• D. All of the above

Correct answer: D

Rationale: Cholecystitis is a correct answer. A history of gallbladder disease, such as cholecystitis, is a contraindication for the use of oral contraceptives. Hypertension is a correct answer. Hypertension is also a contraindication for the use of oral contraceptives due to the increased risk of complications. Migraine headaches are a correct answer. A history of migraine headaches is a contraindication for the use of oral contraceptives, especially for those with aura. Selecting 'All of the above' is correct as all the mentioned conditions (cholecystitis, hypertension, and migraine headaches) are contraindications for oral contraceptives. Human papillomavirus and anxiety disorder are incorrect choices as they are not contraindications for the use of oral contraceptives.

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