Nursing Elites

1. When should the LPN/LVN encourage the laboring client to begin pushing?

• A. When there is only an anterior or posterior lip of the cervix left.
• B. When the client describes the need to have a bowel movement.
• C. When the cervix is completely dilated.
• D. When the cervix is completely effaced.

Correct answer: C

Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal. Choices A, B, and D are incorrect because pushing before complete dilation can be harmful and may not effectively help in the descent of the baby. The presence of an anterior or posterior lip of the cervix, the urge to have a bowel movement, or complete effacement of the cervix are not indicators for the initiation of pushing during labor.

2. A newborn with a yellow abdomen and chest is being assessed. What should be the nurse's initial action?

• A. Assess bilirubin level.
• B. Administer phototherapy.
• C. Encourage feeding to help reduce bilirubin levels.
• D. Perform a bilirubin test every hour.

Correct answer: A

Rationale: The correct action when assessing a newborn with a yellow abdomen and chest is to initially assess the bilirubin level. This helps determine the severity of jaundice in the newborn. Administering phototherapy (choice B) is a treatment intervention that follows the assessment. Encouraging feeding (choice C) can help with bilirubin excretion but is not the initial assessment. Performing a bilirubin test every hour (choice D) may not be necessary initially and could lead to unnecessary interventions.

3. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?

• A. Drowsiness and bradycardia.
• B. Depressed reflexes and increased respirations.
• C. Tachycardia and a feeling of nervousness.
• D. A flushed, warm feeling and a dry mouth.

Correct answer: C

Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.

4. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the

• A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
• B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
• C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
• D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

Correct answer: D

Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.

5. The healthcare provider is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the healthcare provider is administering this medication?

• A. Prevent hemorrhagic disorders.
• B. Help an immature liver.
• C. Improve insufficient dietary intake.
• D. Stimulate the immune system.

Correct answer: A

Rationale: The correct answer is A: 'Prevent hemorrhagic disorders.' Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease by promoting blood clotting. Newborns are born with low levels of vitamin K, which is essential for blood clotting, hence the administration to prevent hemorrhagic disorders. Choice B is incorrect because phytonadione is not given to help an immature liver but to supply vitamin K. Choice C is incorrect as phytonadione is not administered to improve dietary intake but to provide essential vitamin K. Choice D is incorrect as phytonadione does not stimulate the immune system but helps with blood clotting.

Similar Questions