Nursing Elites

1. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

• A. Administer oxygen by face mask.
• B. Notify the healthcare provider of the client's symptoms.
• C. Have the client breathe into her cupped hands.
• D. Check the client's blood pressure and fetal heart rate.

Correct answer: C

Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.

2. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the client's nursing care plan?

• A. Assess temperature every hour.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations every 4 hours.
• D. Keep an airway at the bedside.

Correct answer: D

Rationale: In the case of eclampsia, the priority intervention is to keep an airway at the bedside. Eclampsia is associated with a high risk of convulsions, and having an airway readily available is crucial for prompt intervention in the event of seizures. Assessing temperature, allowing family visitation, and monitoring vital signs are important aspects of care but ensuring airway patency takes precedence in this situation to manage potential complications and ensure the client's safety.

3. When preparing a class on newborn care for expectant parents, what content should be taught concerning the newborn infant born at term gestation?

• A. Milia are white marks caused by sebaceous glands and typically resolve within 2 to 4 weeks.
• B. Meconium is the first stool and is typically dark green or black in color.
• C. Vernix caseosa is a white, cheesy substance mainly found in skin folds, providing a protective layer.
• D. Pseudostrabismus in newborns usually self-resolves without the need for intervention.

Correct answer: C

Rationale: Vernix caseosa is a white, cheesy substance that acts as a protective barrier on the skin of newborns, particularly present in skin folds. It helps to prevent dehydration and protect the delicate skin of the newborn from the amniotic fluid in utero. Educating expectant parents about the presence and function of vernix caseosa can help them understand the importance of its preservation during the immediate postnatal period. Choices A, B, and D are incorrect as they do not directly relate to the protective function of vernix caseosa in newborns. Milia are small, white bumps on the skin due to blocked oil glands, meconium is the first stool of a newborn and is typically dark green or black in color, and pseudostrabismus refers to false appearance of misalignment of the eyes, which usually resolves on its own without intervention.

4. 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.

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.

Similar Questions