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 preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?

• A. Rh incompatibility
• B. Severe preeclampsia
• C. Placental abruption
• D. Erythroblastosis fetalis

Correct answer: A

Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.

3. A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?

• A. You should expect to feel your baby move at 12 weeks.
• B. You will need to increase your calcium intake during pregnancy.
• C. You should avoid exercise during the second trimester.
• D. You will need to limit your intake of folic acid during pregnancy.

Correct answer: B

Rationale: The correct answer is B. Calcium intake is crucial during pregnancy to support fetal bone development. The nurse should educate the client to increase their calcium intake. Choice A is incorrect because fetal movements are usually felt around 18-25 weeks, not at 12 weeks. Choice C is incorrect as exercise is generally encouraged during pregnancy, including the second trimester, as long as it is not high-impact or risky. Choice D is incorrect as folic acid intake is essential during pregnancy to prevent neural tube defects, and pregnant individuals are usually advised to increase their folic acid intake.

4. 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.

5. A newborn delivered at 41 weeks of gestation is showing signs of postmaturity. Which of the following findings is an indication of fetal postmaturity?

• A. Soft, flexible ear cartilage
• B. Smooth soles without creases
• C. Thin with loose skin
• D. Vernix caseosa covering the body

Correct answer: C

Rationale: The correct answer is C: 'Thin with loose skin.' Postmature newborns are typically thin with loose skin due to prolonged gestation. This may result from placental insufficiency, leading to reduced subcutaneous fat stores. Choices A, B, and D are incorrect. Soft, flexible ear cartilage (choice A) is a normal finding in newborns. Smooth soles without creases (choice B) are also typical in newborns. Vernix caseosa covering the body (choice D) is a protective, waxy coating found on newborns, which may be present in postmature infants as well.

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