Nursing Elites

1. A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

• A. Assess deep tendon reflexes every hour.
• B. Obtain a daily weight.
• C. Continuous fetal monitoring
• D. Ambulate twice daily

Correct answer: D

Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.

2. A client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?

• A. Fetal heart rate 100/min
• B. Weakened uterine contractions
• C. Enhanced production of fetal lung surfactant
• D. Maternal blood glucose 63 mg/dL

Correct answer: B

Rationale: Terbutaline is a tocolytic medication that works by relaxing the uterine muscles, leading to weakened uterine contractions. This effect helps to prevent preterm labor. Therefore, the nurse should expect weakened uterine contractions in a client who has received terbutaline at 28 weeks of gestation. Choices A, C, and D are incorrect. Terbutaline administration would not directly affect the fetal heart rate, enhance fetal lung surfactant production, or cause maternal hypoglycemia.

3. When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?

• A. Babinski
• B. Rooting
• C. Moro
• D. Stepping

Correct answer: B

Rationale: The correct answer is B: Rooting. The rooting reflex is crucial in newborns as it helps them locate the nipple for feeding. This reflex involves turning the head towards a stimulus that touches the cheek or mouth, aiding in the process of latching onto the breast for breastfeeding. The Babinski reflex is the fanning out and curling of the toes when the sole of the foot is stroked, the Moro reflex is the startle reflex in response to a sudden noise or movement, and the stepping reflex is the appearance of taking steps when an infant is held upright with feet touching a solid surface. Therefore, choices A, C, and D are incorrect as they do not play a direct role in promoting a newborn to latch during breastfeeding.

4. A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

• A. 22/min
• B. 48/min
• C. 100/min
• D. 110/min

Correct answer: B

Rationale: The expected respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48 breaths per minute falls within this range, indicating normal respiratory function for a newborn. Choice A (22/min) is below the expected range, Choices C (100/min) and D (110/min) are above the expected range for a newborn's respiratory rate.

5. When assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?

• A. Oxygen saturation
• B. Body temperature
• C. Serum bilirubin
• D. Heart rate

Correct answer: A

Rationale: In a newborn with respiratory distress syndrome who has received synthetic surfactant, monitoring oxygen saturation is crucial to evaluate the effectiveness of the treatment. Oxygen saturation levels provide valuable information about the newborn's respiratory status and the adequacy of gas exchange. Changes in oxygen saturation can indicate improvements or deterioration in the newborn's condition following the administration of synthetic surfactant. Monitoring oxygen saturation helps the nurse assess the newborn's response to treatment and make timely interventions if needed. Body temperature, serum bilirubin, and heart rate are important parameters to monitor in newborns for other conditions but are not specific indicators of the effectiveness of synthetic surfactant in treating respiratory distress syndrome.

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