Nursing Elites

1. The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?

• A. Collect a urine sample for urinalysis.
• B. Measure vital signs.
• C. Recommend bed rest.
• D. Obtain human chorionic gonadotropin levels.

Correct answer: D

Rationale: In a pregnant client with a fundal height greater than expected at 10 weeks and experiencing scant dark brown vaginal discharge, there is a concern for a molar pregnancy. Assessing human chorionic gonadotropin (hCG) levels is crucial in this situation to confirm or rule out this condition.

2. 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.

3. A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

• A. Inspect the client's face for edema.
• B. Ascertain the frequency of headaches.
• C. Evaluate for a history of cluster headaches.
• D. Observe and time the client's contractions.

Correct answer: A

Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.

4. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

• A. Measure bilirubin levels using transcutaneous bilirubinometry.
• B. Evaluate cord blood Coombs test results.
• C. Review maternal medical records for blood type and Rh factor.
• D. Prepare the newborn for phototherapy.

Correct answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

5. The client is 30 weeks pregnant and experiencing preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?

• A. Betamethasone (Celestone).
• B. Magnesium sulfate.
• C. Terbutaline (Brethine).
• D. Ampicillin.

Correct answer: A

Rationale: Betamethasone (Celestone) is the medication of choice to promote fetal lung maturity in cases of preterm labor. It helps accelerate surfactant production in the fetal lungs, reducing the risk of respiratory distress syndrome. Administering betamethasone to the mother can improve the baby's lung function and overall outcome if preterm birth occurs. Magnesium sulfate is commonly used to prevent seizures in preeclampsia or eclampsia. Terbutaline is a tocolytic agent used to suppress preterm labor contractions. Ampicillin is an antibiotic used for various bacterial infections but does not promote fetal lung maturity.

Similar Questions