Nursing Elites

1. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

• A. Maternal/newborn blood group incompatibility
• B. Absence of vitamin K
• C. Physiologic jaundice
• D. Maternal cocaine abuse

Correct answer: A

Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.

2. A client who is 6 hours postpartum and Rh-negative has an Rh-positive newborn. The client asks why an indirect Coombs test was ordered. Which of the following is an appropriate response by the healthcare provider?

• A. It determines if kernicterus will occur in the newborn.
• B. It detects Rh-negative antibodies in the newborn's blood.
• C. It detects Rh-positive antibodies in the mother's blood.
• D. It determines the presence of maternal antibodies in the newborn's blood.

Correct answer: C

Rationale: The indirect Coombs test is performed to detect Rh-positive antibodies in the mother's blood. In cases where the mother is Rh-negative and the baby is Rh-positive, the mother may develop antibodies against the baby's blood cells, which can lead to hemolytic disease of the newborn. Choice A is incorrect because kernicterus is a complication of severe jaundice, not directly assessed by the indirect Coombs test. Choice B is incorrect as the test aims to detect Rh-positive antibodies, not Rh-negative antibodies in the newborn's blood. Choice D is incorrect as the test is focused on detecting antibodies in the mother's blood, not the newborn's.

3. A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

• A. Maintain the client in the lithotomy position.
• B. Perform vaginal examinations frequently.
• C. Remind the client to bear down with each contraction.
• D. Encourage the client to empty her bladder every 2 hours.

Correct answer: D

Rationale: Encouraging the client to empty her bladder every 2 hours is essential during labor to prevent bladder distention, which can hinder labor progress and cause discomfort. A distended bladder can also lead to potential complications such as uterine atony or increased risk of infection. Choice A is incorrect as maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor and may not be comfortable for the client. Choice B is incorrect because performing vaginal examinations frequently can increase the risk of introducing infection and disrupt the natural progress of labor. Choice C is incorrect as bearing down with each contraction is typically reserved for the second stage of labor when the cervix is fully dilated, not during the active phase of the first stage.

4. A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

• A. The client's room number
• B. The client's telephone number
• C. The client's birth date
• D. The client's medical record number

Correct answer: A

Rationale: The correct answer is A. Using the client's room number as a secondary identifier is not an appropriate method for client identification in healthcare settings. It can lead to confusion and potential errors, especially in a busy environment like a postpartum unit. Room numbers are not unique to individual patients and can change frequently. Instead, healthcare providers should use more reliable and specific identifiers like the client's name, medical record number, or date of birth to ensure accurate identification and safe administration of medications. Choices B, C, and D are more appropriate secondary identifiers for client identification as they are more specific and less prone to errors than room numbers.

5. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?

• A. 1+ pitting sacral edema
• B. 3+ protein in the urine
• C. Blood pressure 148/98 mm Hg
• D. Deep tendon reflexes of +1

Correct answer: D

Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.

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