Nursing Elites

1. The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?

• A. Palpate the client’s bladder.
• B. Check the pH of the vaginal fluid.
• C. Review the fetal heart rate pattern.
• D. Determine cervical dilation.

Correct answer: D

Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications. While checking the client's bladder may be important to ensure it's not distended, determining cervical dilation takes precedence in this scenario. Checking the pH of the vaginal fluid is not relevant in this situation, and reviewing the fetal heart rate pattern, although important, is not the first action to take when the client expresses the need to go to the bathroom.

2. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

• A. Slowly increasing urinary output over the last week.
• B. Respiratory rate changes from the 40s to the 60s.
• C. Changes in apical heart rate from the 180s to the 140s.
• D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.

Correct answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.

3. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

4. After two miscarriages, a client is instructed to increase her daily intake of foods that include folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

• A. Strawberries.
• B. Yogurt.
• C. Collard greens.
• D. Whole milk.

Correct answer: C

Rationale: Collard greens are a good source of folic acid, which is important for preventing neural tube defects, especially in clients with a history of miscarriages. Since the client does not like green leafy vegetables, collard greens could be suggested as an alternative source of folic acid. Yogurt and whole milk do not contain significant amounts of folic acid, and while strawberries are a healthy choice, they are not a high source of folic acid compared to collard greens.

5. An expectant father tells the LPN/LVN he fears that his wife 'is losing her mind.' He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?

• A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
• B. Help him understand that his wife is experiencing normal maternal behaviors and bonding with the baby, and reassure him that these actions are positive.
• C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
• D. Let him know that these behaviors are part of normal maternal-fetal bonding which occur once the mother feels fetal movement.

Correct answer: D

Rationale: The father's concerns about his wife's behaviors can be addressed by explaining that behaviors like talking to the baby and responding to fetal movements are part of normal maternal-fetal bonding. These actions indicate that the mother is connecting with the baby and are positive signs of a healthy pregnancy. The nurse should reassure the father that these behaviors are common and beneficial for the mother-baby relationship during pregnancy.

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