Nursing Elites

1. A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 80/50 mm Hg
• B. Uterine contractions
• C. Urine output 150 mL in 2 hours
• D. Client reports cramping

Correct answer: A

Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.

2. A nurse is providing care to a client who is in active labor. The nurse observes variable decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Administer oxygen at 10 L/min via face mask
• B. Reposition the client from side to side
• C. Increase the rate of the IV infusion
• D. Notify the provider

Correct answer: B

Rationale: The correct action the nurse should take first when observing variable decelerations in the fetal heart rate is to reposition the client from side to side. Variable decelerations are often caused by umbilical cord compression, and repositioning the client can relieve pressure on the cord. Administering oxygen, increasing the IV infusion rate, and notifying the provider can be appropriate actions but repositioning the client takes priority in addressing variable decelerations.

3. A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?

• A. Avoid using a breast pump.
• B. Apply breast milk to the nipples after feedings.
• C. Feed the newborn less frequently.
• D. Use a nipple shield during feedings.

Correct answer: B

Rationale: The correct instruction for the nurse to provide is to advise the client to apply breast milk to the nipples after feedings. Breast milk has healing properties and can help soothe sore nipples. Option A is incorrect because avoiding the use of a breast pump does not directly address nipple soreness. Option C is incorrect as feeding the newborn less frequently can lead to engorgement and further complications. Option D is incorrect as using a nipple shield during feedings may not address the underlying issue of soreness and can sometimes even worsen the situation.

4. A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?

• A. Administer 1 oz of glucose water every 2 hours
• B. Feed the newborn 60 mL of formula every 4 hours
• C. Offer sterile water between feedings
• D. Initiate phototherapy

Correct answer: D

Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.

5. A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?

• A. This medication will help prevent contractions.
• B. This medication will reduce my baby's risk of respiratory distress.
• C. This medication will prevent early labor.
• D. This medication will increase my baby's weight.

Correct answer: B

Rationale: Correct answer: Option B. Betamethasone is a glucocorticoid used to promote fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Option A is incorrect because betamethasone does not prevent contractions. Option C is incorrect as betamethasone does not prevent early labor but helps improve fetal lung development. Option D is incorrect as betamethasone does not increase the baby's weight.

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