Nursing Elites

1. A nurse is using Naegele’s rule to calculate the expected delivery date for a client whose last menstrual period was in October. What is the expected date?

• A. 711
• B. 1011
• C. 411
• D. 1211

Correct answer: A

Rationale: Using Naegele’s rule, to calculate the expected delivery date, you add one year, subtract three months, and add seven days to the first day of the last menstrual period. If the last menstrual period was in October, adding one year gives October of the following year. Subtracting three months gives July, and adding seven days gives the expected delivery date of July 11th. Therefore, the correct answer is 711. Choice B (1011) is incorrect as it doesn't follow Naegele’s rule calculations. Choices C (411) and D (1211) are also incorrect as they do not align with the correct application of Naegele’s rule.

2. A client is being treated for eclampsia. What is a priority nursing intervention?

• A. Assess for hyperreflexia
• B. Administer oxygen
• C. Monitor blood pressure every 15 minutes
• D. Prepare for delivery

Correct answer: A

Rationale: The correct answer is to 'Assess for hyperreflexia.' Eclampsia is a severe complication of pregnancy that involves seizures. Hyperreflexia, an overactive or overresponsive reflex, is often an early sign of impending eclampsia. By assessing for hyperreflexia, nurses can identify this warning sign and take preventive measures to manage the condition before seizures occur. Administering oxygen (Choice B) may be necessary but is not the priority in this situation. Monitoring blood pressure (Choice C) is important but assessing for hyperreflexia takes precedence as it can lead to immediate life-threatening complications. While preparing for delivery (Choice D) may ultimately be necessary, the immediate priority is to assess for hyperreflexia to prevent seizures.

3. A nurse is providing education on the use of aspirin. Which of the following should be included?

• A. It can increase the risk of bleeding
• B. It is safe to give to children
• C. It should be taken on an empty stomach
• D. It has no side effects

Correct answer: A

Rationale: The correct answer is A: 'It can increase the risk of bleeding.' Aspirin is known to have antiplatelet effects and can increase the risk of bleeding, especially if taken in high doses or for prolonged periods. Choice B is incorrect because aspirin is not safe for children due to the risk of Reye's syndrome. Choice C is incorrect because aspirin should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because aspirin, like any medication, can have side effects, such as gastrointestinal bleeding, ulcers, or allergic reactions.

4. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

• A. Nevus simplex
• B. Caput succedaneum
• C. Cephalohematoma
• D. Erythema toxicum

Correct answer: B

Rationale: Caput succedaneum is the correct answer. It is the swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction. Nevus simplex (Choice A) is a pink or red birthmark that is flat and usually fades on its own. Cephalohematoma (Choice C) is a collection of blood between a baby's skull and the periosteum, often caused by birth trauma. Erythema toxicum (Choice D) is a common rash in newborns that is benign and typically resolves on its own. In this case, the description of swelling over the newborn's head crossing the suture line is characteristic of caput succedaneum, which is a common finding in newborns after vaginal delivery.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

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