Nursing Elites

1. What nursing intervention is particularly indicated for the second stage of labor?

• A. Providing pain medication to increase the client’s tolerance of labor
• B. Assessing the fetal heart rate and pattern for signs of fetal distress
• C. Monitoring effects of oxytocin administration to help achieve cervical dilation
• D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved

Correct answer: D

Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.

2. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

• A. Reduce risk factors for infection
• B. Administer high-flow oxygen during sleep
• C. Limit fluid intake to reduce secretions
• D. Use diaphragmatic breathing to achieve better exhalation

Correct answer: D

Rationale: The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.

3. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only
• B. Maintain intravenous fluid therapy per prescription
• C. Provide Pedialyte feedings via the nasogastric tube
• D. Offer the infant Pedialyte feedings every 2 hours

Correct answer: B

Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.

4. A premature infant weighing 1,200 grams at birth receives a prescription for beractant (Survanta) 120 mg endotracheal now and q6 hr for 24 hr. The recommended dose for beractant is 100 mg/kg birth weight per dose. Single-use vials of Survanta are labeled 100 mg/4 ml. What action should the nurse take?

• A. Give 4.8 ml q6 hr
• B. Notify the healthcare provider that the dose is too high
• C. Notify the healthcare provider that the dose is too low
• D. Give 1.2 ml q6 hr

Correct answer: A

Rationale: The correct answer is to give 4.8 ml q6 hr. To calculate the dose, you divide the prescribed dose of 120 mg by the concentration of Survanta, which is 100 mg per 4 ml. This results in 4.8 ml per dose, as 120 mg ÷ 100 mg/4 ml = 4.8 ml. Option B suggesting to notify the healthcare provider that the dose is too high is incorrect because the calculated dose of 4.8 ml is based on the recommended dose of 100 mg/kg birth weight. Option C suggesting to notify the healthcare provider that the dose is too low is incorrect as the calculated dose is based on the correct dosage calculation. Option D suggesting to give 1.2 ml q6 hr is incorrect because it doesn't align with the correct calculation.

5. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant’s record?

• A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
• B. Compare the difference between the infant’s current weight and admission weight.
• C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
• D. Calculate the difference in wet and dry diapers and document 80 ml urine.

Correct answer: C

Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.

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