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. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

• A. Suction the oral and nasal passages.
• B. Give oxygen by positive pressure.
• C. Stimulate the infant to cry.
• D. Turn the infant onto the right side.

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

3. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

4. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?

• A. Notify the healthcare provider immediately.
• B. Suction the infant's nares, then the oral cavity.
• C. Check the infant's oxygen saturation rate.
• D. Position the infant on the right side.

Correct answer: C

Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.

5. A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?

• A. Use an alternative form of contraception until a new diaphragm is obtained.
• B. After weaning, the diaphragm should be resized.
• C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
• D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.

Correct answer: A

Rationale: The nurse should advise the client to use an alternative form of contraception until a new diaphragm that fits correctly post-pregnancy is obtained. It is essential to ensure proper fit for effective contraception, making it crucial to use an alternative method until the diaphragm is resized.

Similar Questions