Nursing Elites

1. One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large, and her fundus is boggy despite massage. The client's pulse is 84 beats/minute, and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the healthcare provider take immediately?

• A. Give the medication as prescribed and monitor for efficacy.
• B. Encourage the client to breastfeed rather than bottle-feed.
• C. Have the client empty her bladder and massage the fundus.
• D. Call the healthcare provider to question the prescription.

Correct answer: D

Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.

2. During an examination for possible cryptorchidism in an infant, what technique should be used?

• A. Place the infant in a warm room and use a calm approach.
• B. Hold the scrotum and palpate gently.
• C. Cleanse the penis with an antiseptic-soaked pad.
• D. Position the infant in a warm room to prevent muscle contraction.

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

3. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

• A. Use a sterile item to tie off the umbilical cord.
• B. Provide privacy for the woman.
• C. Reassure the husband and try to keep him calm.
• D. Put the newborn to breast.

Correct answer: D

Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.

4. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

• A. Inform and assure the mother that this is normal weight loss.
• B. Encourage the mother to increase the frequency of breastfeeding.
• C. After verifying the accuracy of weight, notify the healthcare provider.
• D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

5. The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

• A. A gravida 6, para 5 who is 38 years of age and in early labor.
• B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
• C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
• D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.

Correct answer: D

Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.

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