Nursing Elites

1. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?

• A. Initiate an intravenous infusion.
• B. Observe the FHR pattern for 30 more minutes.
• C. Schedule a biophysical profile.
• D. Place an acoustic stimulator on the abdomen.

Correct answer: D

Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.

2. Upon admission to the prenatal clinic, a 23-year-old woman informs the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What is this client's expected date of delivery (EDD)?

• A. November 22.
• B. November 8.
• C. December 22.
• D. October 22.

Correct answer: A

Rationale: To determine the expected date of delivery (EDD) using Nägele's rule, add 7 days to the first day of the last menstrual period (LMP) which is February 15, resulting in February 22. Then, subtract 3 months from February 22, which gives November 22 as the estimated due date.

3. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?

• A. Allow the child to eat any food desired and tolerated.
• B. Provide small, frequent meals that are high in protein and calories.
• C. Offer the child preferred foods and avoid foods that are not well-tolerated.
• D. Consult with a dietitian to provide appropriate nutritional support.

Correct answer: B

Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.

4. A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn?

• A. Length of labor and method of delivery.
• B. Infant's condition at birth and treatment received.
• C. Feeding method chosen by the parents.
• D. History of drugs given to the mother during labor.

Correct answer: B

Rationale: When a full-term infant is transferred to the nursery, the most crucial information for the LPN/LVN to receive for immediate care planning is the infant's condition at birth and any treatments received. This data helps in determining the initial care needs and monitoring requirements for the newborn. Choices A, C, and D are not as critical as the infant's condition at birth and treatment received. The length of labor and method of delivery may provide background information but may not be as essential for immediate care planning. The feeding method chosen by the parents and the history of drugs given to the mother during labor are important but do not take precedence over knowing the infant's condition and treatment received.

5. At 40 weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home and is in active labor. The client feels the need to bear down and push. What information is most important for the nurse to obtain first?

• A. Estimated amount of fluid.
• B. Any odor noted when membranes ruptured.
• C. Color and consistency of fluid.
• D. Time the membranes ruptured.

Correct answer: C

Rationale: The color and consistency of the amniotic fluid are crucial to assess as they can provide valuable information about the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can lead to complications such as meconium aspiration syndrome in the newborn. Therefore, assessing the color and consistency of the amniotic fluid is the priority in this situation to ensure timely interventions if needed. Estimated amount of fluid (Choice A) may be important but not as critical as assessing for meconium. Any odor noted when membranes ruptured (Choice B) is less relevant compared to assessing for meconium. Knowing the time the membranes ruptured (Choice D) is important but does not take precedence over assessing for fetal distress indicated by meconium presence.

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