Nursing Elites

1. A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?

• A. Use a condom with sexual intercourse
• B. Avoid bubble bath solution when taking a tub bath
• C. Wipe from front to back when performing perineal hygiene
• D. Keep a daily record of fetal kick counts

Correct answer: D

Rationale: Keeping a daily record of fetal kick counts is crucial for clients with premature rupture of membranes at 26 weeks of gestation as it helps monitor fetal well-being. This activity enables the client to assess the frequency and strength of fetal movements, which can provide important information about the fetus' health and development. Other options such as using a condom with sexual intercourse, avoiding bubble bath solution, and wiping from front to back are important for general perinatal care but are not specifically related to managing premature rupture of membranes.

2. A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?

• A. Vastus lateralis
• B. Ventrogluteal
• C. Dorsogluteal
• D. Deltoid

Correct answer: A

Rationale: Vitamin K is typically administered in the vastus lateralis muscle of a newborn to prevent bleeding disorders. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and accessibility, allowing for easy and safe administration. The ventrogluteal and dorsogluteal sites are more commonly used in adults due to better muscle mass and less risk of injury to nearby structures. The deltoid muscle is typically used for older children and adults for IM injections, as it is a well-developed muscle suitable for injections in these populations.

3. A client who is at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding, with a tentative diagnosis of inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

• A. Administer oxygen via nasal cannula.
• B. Offer the option to view products of conception.
• C. Instruct the client to increase potassium-rich foods in the diet.
• D. Maintain the client on bed rest.

Correct answer: B

Rationale: In cases of inevitable abortion, offering the option to view products of conception can assist in emotional healing and closure for the client. This can provide a sense of acknowledgment and closure for the loss experienced, aiding in the grieving process. Administering oxygen via nasal cannula (choice A) is not directly related to the emotional and psychological support needed during an inevitable abortion. Instructing the client to increase potassium-rich foods (choice C) may not be a priority in this situation. Maintaining the client on bed rest (choice D) may be indicated in some cases but does not address the emotional aspect of the situation.

4. A healthcare provider is instructing a client who is taking an oral contraceptive about manifestations to report. Which of the following manifestations should the healthcare provider include?

• A. Reduced menstrual flow
• B. Breast tenderness
• C. Shortness of breath
• D. Increased appetite

Correct answer: C

Rationale: Shortness of breath is a symptom that can indicate a serious side effect of oral contraceptives, such as a potential blood clot in the lungs. This condition requires immediate medical attention to prevent complications. Choices A, B, and D are not typically associated with serious side effects of oral contraceptives and are considered normal or common side effects that do not require urgent medical attention.

5. A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?

• A. Epidural analgesia
• B. Naloxone hydrochloride
• C. Attention-focusing
• D. Pudendal nerve block

Correct answer: C

Rationale: Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.

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