Nursing Elites

1. The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client?

• A. Clonidine hydrochloride
• B. Carbamazepine
• C. Furosemide
• D. Magnesium sulfate

Correct answer: D

Rationale: In the scenario presented, the client is exhibiting signs and symptoms of severe preeclampsia, including hypertension, proteinuria, facial and hand swelling, visual disturbances, and a severe headache. The medication of choice for preventing seizures in preeclampsia is magnesium sulfate. This drug helps to prevent and control seizures in clients with preeclampsia, making it the most appropriate option for this client. Clonidine hydrochloride (Choice A) is an antihypertensive medication used for managing hypertension but is not the first-line treatment for preeclampsia. Carbamazepine (Choice B) is an anticonvulsant used for seizure disorders like epilepsy and is not indicated for preeclampsia. Furosemide (Choice C) is a diuretic used to manage fluid retention but is not the drug of choice for treating preeclampsia.

2. During a non-stress test (NST) at 41-weeks gestation, the LPN/LVN notes that the client is not experiencing contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are present. What action should the nurse take?

• A. Check the client for urinary bladder distention.
• B. Notify the healthcare provider of the nonreactive results.
• C. Have the mother stimulate the fetus to move.
• D. Ask the client if she has felt any fetal movement.

Correct answer: D

Rationale: In this scenario, the nurse should ask the client if she has felt any fetal movement. This action is important as assessing for fetal movement can help determine if the absence of FHR accelerations is attributed to fetal sleep or decreased fetal activity. It is crucial to gather information directly from the client to aid in the assessment and decision-making process. This approach can provide valuable insights into the fetal well-being and guide further interventions if needed.

3. What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?

• A. Administer prescribed IV solution.
• B. Give oral rehydration solution.
• C. Encourage small, frequent meals.
• D. Offer ginger tea to reduce nausea.

Correct answer: A

Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.

4. A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

• A. Advise the mother to wait at least another month before starting any solid foods.
• B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
• C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
• D. Encourage the mother to schedule a developmental assessment of the infant.

Correct answer: C

Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding. Choice A is incorrect because waiting another month is not necessary if the infant is 6 months old. Choice B is incorrect as introducing pureed fruits as the first food may not provide the necessary iron that the infant needs at this stage. Choice D is also incorrect as scheduling a developmental assessment is not indicated solely based on the desire to start solid foods; it is more appropriate to reassure the mother about starting iron-fortified cereal.

5. While preparing a 10-year-old with a lacerated forehead for suturing, the nurse notices both parents and a 12-year-old sibling at the child’s bedside. Which instruction best supports the family's involvement?

• A. While waiting for the healthcare provider, only one visitor may stay with the child.
• B. All of you should leave while the healthcare provider sutures the child’s forehead.
• C. It is best if the sibling goes to the waiting room until the suturing is completed.
• D. Please decide who will stay when the healthcare provider begins suturing.

Correct answer: D

Rationale: Involving the family by letting them decide who will stay during the suturing process promotes family engagement and comfort, ensuring the presence of a familiar person for the child during the procedure.

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