Nursing Elites

1. A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?

• A. Schedule a visit with the healthcare provider today.
• B. Verify the compatibility of the administered Rho(D) immune globulin.
• C. Encourage the client to increase her intake of oral fluids.
• D. Instruct the client to maintain bedrest for 24 hours.

Correct answer: C

Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.

2. A neonate with congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

• A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
• B. Support the parents in their decision regarding the sex assignment of their child
• C. Offer information about ultrasonography and genotyping to determine sex assignment
• D. Explain that corrective surgical procedures consistent with sex assignment can be delayed

Correct answer: B

Rationale: Supporting the parents in their decision regarding the sex assignment of their child is crucial as it respects the parental role in making this important decision and helps provide emotional support during a challenging time. The primary focus should be on helping the parents navigate the complexities and implications of determining the sex assignment for their child with ambiguous genitalia.

3. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

• A. 3+ deep tendon reflexes and hyperreflexia.
• B. Periorbital edema, flashing lights, and aura.
• C. Epigastric pain in the third trimester.
• D. Recent decreased urinary output.

Correct answer: A

Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.

4. What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?

• A. Maternal blood pressure.
• B. Level of pain sensation.
• C. Station of presenting part.
• D. Variability of fetal heart rate.

Correct answer: A

Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia. The other options, such as assessing the level of pain sensation, station of presenting part, and variability of fetal heart rate, are important in obstetric care but are not as critical as monitoring maternal blood pressure to prevent complications related to epidural anesthesia administration.

5. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

• A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
• B. Growth and development have been abnormal since birth.
• C. Muscular strength can be regained with physical exercise and therapy.
• D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.

Correct answer: A

Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.

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