1 :

0830:

42-week primigravida in active labor with membranes intact. 60% effaced, 6 cm dilated.

0830:

Baseline FHR 140s with moderate variability. Contractions moderate, 60 to 80 seconds in duration.

0900:

Membranes intact, 70% effaced, 8 cm dilated. Baseline FHR 140s with moderate variability. 2 late decelerations since 0830. Contractions moderate, 60 to 80 seconds in duration.

0930:

Membranes intact, 70% effaced, 8 cm dilated. Baseline FHR 140s with minimal variability. Late decelerations noted with each contraction. Contractions moderate, 60 to 80 seconds in duration. Provider notified re: persisting deceleration.

0945:

Amniotomy performed by provider. Thick green amniotic fluid.


Drag words from the choices below to fill in each blank In the following sentence. Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing and


Hint : 🫁 Post-term = lungs + size

Correct Answers

  • Blank 1 Correct Option: Meconium aspiration syndrome
  • Blank 2 Correct Option: macrosomia

Rationale :

🔴 Meconium aspiration syndrome

🔻 Post-term infants are at increased risk of hypoxia, which can lead to meconium passage in utero.

🔻 The presence of thick green amniotic fluid after amniotomy suggests meconium-stained fluid.

🔻 This raises concern for aspiration of meconium into the lungs, leading to respiratory distress.

🔻 Close respiratory monitoring and possible NICU evaluation are necessary.

🟠 Macrosomia

🟡 Post-term gestation increases the risk of fetal overgrowth due to prolonged exposure to maternal nutrients.

🟡 Macrosomia is a known complication of pregnancies exceeding 42 weeks.

🟡 This condition increases the risk for birth trauma, shoulder dystocia, and hypoglycemia after birth.


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2 :

Hint : ⏱ Infuse vancomycin slowly

Correct Answers:

  • Give the dose over 60 min.


Rationale :

🔵 Vancomycin should be administered slowly over at least 60 minutes to reduce the risk of "Red man syndrome," a histamine-mediated reaction.

🔵 Rapid infusion can cause flushing, hypotension, and pruritus, which are preventable with slow administration.

🔵 This strategy minimizes adverse effects without requiring additional medications or pre-treatment.

🔵 Following this guideline ensures safer delivery and client comfort.


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3 :

Day 1, 0700:

72-year-old client was admitted to preoperative holding for right hip total arthroplasty. Client has a history of hypertension and COPD. Client had left hip total arthroplasty 4 years ago. Client has smoked half a pack of cigarettes per day for 50 years. Denies alcohol or illicit drug use.

Day 1, 0700:

Client is sitting quietly in no distress. S1 and S2 auscultated; no murmur, gallop, or rub noted. Breath sounds noted to have faint wheezing bilaterally. Client has a barrel chest. Client moves all extremities well.

1400:

Client admitted to the medical-surgical unit following the procedure. Client reports pain as 7 on a scale of 0 to 10. Operative leg supported with pillows. Abduction device secured.

Day 2, 0700:

Client states, "l feel pretty good, considering." Client requests a cup of ice for dry mouth. Reports pain as 4 on a scale of 0 to 10. Instructed client regarding coughing and deep breathing exercises. Encouraged client to continue to use incentive spirometer.

1000:

Nurse called to the client's room. Client's family reports that client became short of breath "out of nowhere." Client noted to be diaphoretic and agitated. Tachycardia noted. Breath sounds noted to have faint wheezing with crackles bilaterally. Equal chest expansion, barrel chest. Right leg immobilized, 1+ edema to the right leg. Abduction device straps loose.

Day 1, 0700:

Temperature 370 C (98.60 F)

BP 158/78 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Oxygen saturation 98% on room air

Weight 136 kg (299.8 lb)

Height 177.8 cm (70 inches)

BMI 43.2

Day 2, 1000:

Temperature 370 C (98.60 F)

BP 162/90 mm Hg

Heart rate 111/min

Respiratory rate 24/min

Oxygen saturation 91% on room air


Click to highlight the findings that can indicate an acute complication of the client's condition. To deselect a finding, click on the finding again.


Body System Findings General Diaphoretic, agitated Cardiovascular S1, S2 no murmur, gallop or rub. Respiratory Faint wheezing bilaterally, bilateral crackles. Equal chest expansion, barrel chest Extremities R leg immobilized, 1+ edema bilaterally. Abduction device straps loose. Vital Signs BP 162/89 mm Hg Heart rate 111/min Respiratory rate 24/min Oxygen saturation on room air Temperature 37.05°F

Hint : 🫁 Tachypnea + crackles = red flag

Correct Highlights :
  • Diaphoretic, agitated
  • bilateral crackles.
  • Respiratory rate 24/min
  • Heart rate 111/min

Rationale :

🔴 Diaphoretic, agitated

🔻 These signs suggest increased sympathetic response, which may occur during a pulmonary embolism or respiratory compromise.

🔻 Acute changes in mental status and behavior warrant immediate follow-up.

🔻 These could indicate a worsening oxygenation issue or cardiac strain.

🔴 Bilateral crackles

🟡 Crackles reflect fluid in the alveoli, often seen in congestive heart failure, pulmonary embolism, or other causes of impaired gas exchange.

🟡 This is a significant change from previous faint wheezing and requires urgent respiratory assessment.

🔴 Respiratory rate 24/min

🔷 Tachypnea is a compensatory response to impaired oxygenation or acid-base imbalance.

🔷 This rate, along with crackles and low SpO₂ trends, supports a developing complication, like a PE.

🔴 Heart rate 111/min

🟢 Tachycardia in a post-op patient with respiratory symptoms could indicate hypoxemia, sepsis, or a thromboembolic event.

🟢 It is especially concerning in a client with immobility and risk factors such as COPD and obesity.


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4 :

Hint : 🧠 Assess coping first

Correct Answers:

  • Determine the client's coping methods.


Rationale :

🟣 The first step in a smoking cessation plan is assessment, including evaluating how the client currently copes with stress and cravings.

🟣 Understanding these coping strategies helps individualize the care plan and select appropriate behavioral or pharmacologic interventions.

🟣 This approach ensures the nurse aligns interventions with the client’s psychological readiness to change.

🟣 Without this foundation, further steps may not be effective or client-centered.


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5 :

Hint : 🩸 Check platelets before epidural

Correct Answers:

  • Review the client's platelet count level prior to the procedure.


Rationale :

🟤 Epidural analgesia carries a risk of epidural hematoma, especially in clients with low platelet counts.

🟤 Reviewing laboratory results helps prevent complications associated with bleeding into the epidural space.

🟤 This is a critical safety measure to avoid potentially irreversible neurological damage.

🟤 It should be done before the initiation of anesthesia to ensure it is safe to proceed.


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6 :

Hint : 🎯 Reinforce coping success

Correct Answers:

  • Give positive feedback to the client for using adaptive coping strategies.


Rationale :

⚪ Providing positive reinforcement helps the client build confidence in adaptive behaviors and strengthens motivation for change.

⚪ This approach supports the development of healthier stress management techniques, reducing the reliance on alcohol.

⚪ Acknowledging small successes fosters self-efficacy, which is crucial in maintaining behavior modification in substance use recovery.

⚪ Therapeutic communication should always validate progress and encourage consistency in healthier choices.


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7 :

Hint : 💊 Check for allergies first

Correct Answers:

  • Review the client's allergy history.


Rationale :

🔴 Reviewing allergy history is the priority action before administering a beta-lactam antibiotic like cefazolin.

🔴 Cephalosporins can cause cross-reactivity in clients allergic to penicillin, and reactions can be severe or life-threatening.

🔴 This step ensures safe medication administration and prevents adverse events such as anaphylaxis.

🔴 Allergy checks are a standard component of the rights of medication administration.


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8 :

Hint : 🛟 Practice disaster readiness

Correct Answers:

  • Participate in community drills and mock events.


Rationale :

🟠 Participation in mock drills and simulated disasters allows nurses to develop competence and readiness in real emergency scenarios.

🟠 This prepares healthcare teams for efficient and coordinated responses, ensuring public safety.

🟠 Nurses play an essential role in preparedness, and active involvement enhances their understanding of roles and resources.

🟠 It also builds collaboration among interdisciplinary and public health teams.


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9 :

Hint : 🗣️ SLP = swallowing help

Correct Answers:

  • Speech-language pathologist


Rationale :

🟡 A speech-language pathologist evaluates and manages swallowing difficulties (dysphagia) to reduce the risk of aspiration.

🟡 They can recommend appropriate food textures, feeding techniques, and rehabilitation exercises.

🟡 Early referral can prevent aspiration pneumonia and improve nutritional intake in older adults.

🟡 This is essential in long-term care settings where complications can be severe.


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10 :

Day 2:

Physical Examination:

Infant appears lethargic, generalized lymphadenopathy noted. Clear drainage from both nares, small white spots noted to buccal mucosa. Bilateral breath sounds clear, non-productive cough. Abdomen soft, non-distended, non-tender.  Erythematous, maculopapular rash to the face with some progression down the chest and upper arms. The infant's vaccinations are up to date.

Day 1:

Parent of a 5-month-old infant called to report a fever of 38.3°C (100.9°F) in the morning. Parent has given acetaminophen, and the fever has come down to 37.5°C (99.5°F). Parent reports infant has a runny nose, cough, and white spots in the mouth. Infant has been breastfeeding regularly and having wet diapers.

Recommended continued monitoring of fever and giving weight-based acetaminophen every 6 hr PRN. Appointment for infant to see provider the next day.

Day 2:

Infant brought to clinic by parent. Parent states the fever has not been greater than 37.8°C (100°F) for over 24 hr. Cough and runny nose persist. Infant is also lethargic and has developed a rash.


Click to specify if each finding is indicative of fifth disease. measles, or rubella. Each finding may support more than one disease process.


Assessment Finding Fifth disease (Erythema infectiosum) Measles (Rubeola) Rubella (German measles
Red rash on the face
Fever
Koplik spots in the mouth
Lymphadenopathy

Hint : 🧒 Koplik = only measles

Correct Answers

  • Red rash on the face [ Fifth disease (Erythema infectiosum) ; Measles (Rubeola) ; Rubella (German measles ]
  • Fever [ Fifth disease (Erythema infectiosum) ; Measles (Rubeola) ; Rubella (German measles ]
  • Koplik spots in the mouth [ Measles (Rubeola) ]
  • Lymphadenopathy [ Measles (Rubeola) ; Rubella (German measles ]

Rationale :

Red rash on the face

🟤 All three conditions may begin with a facial rash, but the pattern differs. Fifth disease often presents as a “slapped cheek” appearance.

🟤 Measles starts on the face and spreads downward as a maculopapular rash. Rubella also begins on the face but tends to be lighter and resolves quicker.

Fever

🟤 Fever is a nonspecific systemic sign seen in all three viral illnesses.

🟤 In measles, the fever is usually high and prolonged. In rubella and fifth disease, fever is typically milder and shorter.

Koplik spots in the mouth

🟤 Koplik spots are unique to measles, appearing as tiny white or bluish-white spots on the buccal mucosa.

🟤 These are a pathognomonic sign and appear before the rash, helping confirm the diagnosis early.

Lymphadenopathy

🟤 Rubella is known for causing posterior auricular and occipital lymphadenopathy, especially in children.

🟤 Measles can also lead to generalized lymphadenopathy due to systemic viral spread.

🟤 Fifth disease typically does not involve lymphadenopathy.


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Total Questions: 10

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