Nursing Elites

1. An antepartum client is Rh negative and understands that she will receive a RhoGAM injection during her pregnancy. The client asks the nurse if she will also receive a RhoGAM injection after the birth of her baby. The client will receive RhoGAM after the birth if blood tests are:

• A. Mother Rh positive; baby Rh negative
• B. Mother Rh negative; Coombs positive; baby Rh negative
• C. Mother Rh positive; Coombs negative; baby Rh positive
• D. Mother Rh negative; Coombs negative; baby Rh positive

Correct answer: D

Rationale: The correct answer is D. If the baby is Rh positive and the mother is Rh negative, the mother may develop antibodies against the baby's blood. RhoGAM is administered to prevent the mother's immune system from becoming sensitized to Rh-positive blood. Therefore, the mother, who is Rh negative, will receive RhoGAM after birth if the baby is Rh positive and both the mother and baby have negative Coombs tests. Choices A, B, and C are incorrect because they do not match the criteria for RhoGAM administration in this scenario.

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 preparing to administer a dose of digoxin. Which of the following should the nurse do first?

• A. Assess blood pressure
• B. Check heart rate
• C. Monitor potassium levels
• D. Review the medication order

Correct answer: B

Rationale: The correct answer is to check the heart rate first before administering digoxin. Digoxin is a medication that directly affects the heart, so it is crucial to ensure that the heart rate is within the appropriate range before giving the dose. If the heart rate is below 60 bpm, administering digoxin could lead to toxicity. Assessing blood pressure (Choice A) is important but not the first priority when preparing to administer digoxin. Monitoring potassium levels (Choice C) is also crucial for patients on digoxin, but it is not the initial step. Reviewing the medication order (Choice D) is necessary but can be done after checking the heart rate.

4. A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?

• A. Restrain the client
• B. Place the client on their side with their head forward
• C. Perform a neurological assessment
• D. Monitor the client's vitals every 2 minutes

Correct answer: B

Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.

5. A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Hypertonia
• B. Jitteriness
• C. Acrocyanosis
• D. Generalized petechiae

Correct answer: B

Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy. Choice A, Hypertonia, is not typically associated with hypoglycemia but rather with conditions like hypocalcemia. Acrocyanosis (Choice C) is a benign condition characterized by peripheral cyanosis and is not directly linked to hypoglycemia. Generalized petechiae (Choice D) are tiny red or purple spots on the skin due to bleeding and are not specific to hypoglycemia.

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