Nursing Elites

1. A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?

• A. Tachycardia
• B. Hyperreflexia
• C. Respiratory rate of 10/min
• D. Polyuria

Correct answer: C

Rationale: Corrected Rationale: Magnesium sulfate can cause respiratory depression, leading to a decreased respiratory rate. A respiratory rate of 10/min is abnormally low and indicates magnesium toxicity. Tachycardia (Choice A) is not typically associated with magnesium toxicity. Hyperreflexia (Choice B) is a common sign of magnesium toxicity. Polyuria (Choice D) is not a typical finding of magnesium toxicity.

2. A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?

• A. Contraction frequency of every 3 minutes
• B. Contraction duration of 80 seconds
• C. Late decelerations in the fetal heart rate
• D. Urine output of 50 mL/hr

Correct answer: C

Rationale: Late decelerations in the fetal heart rate require immediate intervention as they can indicate fetal distress due to uteroplacental insufficiency. This finding suggests a compromised blood flow to the fetus, which can lead to serious complications if not addressed promptly. Contraction frequency and duration are important to monitor but do not necessitate immediate intervention unless they are causing fetal distress. Urine output of 50 mL/hr is within the normal range for a client in labor and does not require immediate intervention.

3. A healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?

• A. Respiratory rate 50/min
• B. Blood glucose 30 mg/dL
• C. Blood pressure 60/40 mm Hg
• D. Heart rate 140/min

Correct answer: B

Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.

4. A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should eat foods high in protein before bedtime.
• B. You should avoid consuming liquids with your meals.
• C. You should eat three large meals per day.
• D. You should consume caffeine to help with nausea.

Correct answer: B

Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.

5. A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 160/min
• B. Axillary temperature 36.8°C (98.2°F)
• C. Yellow-tinged skin
• D. Respiratory rate 42/min

Correct answer: C

Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.

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