Nursing Elites

1. A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

• A. Palpate the fundus to identify the fetal part.
• B. Determine the location of the fetal back.
• C. Palpate for the fetal part presenting at the inlet.
• D. All of the Above

Correct answer: D

Rationale: The correct sequence for the nurse to follow when performing Leopold maneuvers is as follows: first, palpate the client's fundus to identify the fetal part, second, determine the location of the fetal back, third, palpate for the fetal part presenting at the inlet, and finally, palpate the cephalic prominence to identify the attitude of the head. Therefore, option D, 'All of the Above,' is the correct answer as it includes all the steps in the correct sequence. Choices A, B, and C are incorrect as they do not represent the complete sequence required for performing Leopold maneuvers.

2. After an amniotomy, what is the priority nursing action?

• A. Observe color and consistency of fluid
• B. Assess the fetal heart rate pattern
• C. Assess the client's temperature
• D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation

Correct answer: B

Rationale: After an amniotomy, the priority nursing action is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress, as changes in the fetal heart rate could indicate potential complications related to the procedure. Observing the color and consistency of the fluid (Choice A) is important but not the priority over assessing fetal well-being. Assessing the client's temperature (Choice C) and evaluating the client for chills and increased uterine tenderness (Choice D) are not immediate priorities following an amniotomy.

3. A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

• A. The client's room number
• B. The client's telephone number
• C. The client's birth date
• D. The client's medical record number

Correct answer: A

Rationale: The correct answer is A. Using the client's room number as a secondary identifier is not an appropriate method for client identification in healthcare settings. It can lead to confusion and potential errors, especially in a busy environment like a postpartum unit. Room numbers are not unique to individual patients and can change frequently. Instead, healthcare providers should use more reliable and specific identifiers like the client's name, medical record number, or date of birth to ensure accurate identification and safe administration of medications. Choices B, C, and D are more appropriate secondary identifiers for client identification as they are more specific and less prone to errors than room numbers.

4. A client is receiving postpartum discharge teaching after being vaccinated for varicella due to lack of immunity. Which statement by the client indicates understanding?

• A. I will need a second vaccination at my postpartum visit.
• B. I need a second vaccination at my postpartum visit.
• C. I was given the vaccine to protect myself from varicella.
• D. I will be tested in 3 months to confirm my immunity status.

Correct answer: B

Rationale: The correct answer is B because the client needs a second varicella vaccination at the postpartum visit to ensure immunity. Option A is incorrect as it implies a future need for a second vaccination without a clear action plan. Option C is incorrect as the varicella vaccine is primarily for the client's protection, not others. Option D is not the appropriate action as waiting to be tested for immunity delays the necessary second vaccination.

5. In a prenatal clinic, a client in the first trimester of pregnancy has a health record that includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply)

• A. Client has delivered one newborn at term
• B. Client has experienced no preterm labor
• C. Client has had two prior pregnancies
• D. ALL OF THE ABOVE - has one living child

Correct answer: D

Rationale: The client's health record data is interpreted as follows: G3 (gravida 3 - total number of pregnancies), T1 (term births - number of full-term deliveries), P0 (preterm births - number of preterm deliveries), A1 (abortions/miscarriages - total number of miscarriages or abortions), L1 (living children - total number of living children). Therefore, the client has had three pregnancies, one full-term delivery, no preterm labor, one miscarriage/abortion, and one living child. The correct interpretation is that the client has delivered one newborn at term, experienced no preterm labor, had two prior pregnancies, and has one living child. Therefore, choice D is correct. Choices A, B, and C are incorrect as they do not provide a comprehensive interpretation of all aspects of the client's health record data.

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