Nursing Elites

1. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

• A. Inform and assure the mother that this is normal weight loss.
• B. Encourage the mother to increase the frequency of breastfeeding.
• C. After verifying the accuracy of weight, notify the healthcare provider.
• D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

2. 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.

3. 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.

4. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?

• A. Turn off the oxytocin infusion.
• B. Reposition the fetal monitor transducers.
• C. Decrease the rate of the oxytocin infusion.
• D. Alert the charge nurse about the patient's condition.

Correct answer: A

Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.

5. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

• A. Pain level
• B. Blood pressure
• C. Infusion site
• D. Contraction pattern

Correct answer: D

Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.

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