Nursing Elites

1. A nurse is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?

• A. Client reports constipation
• B. Client reports swelling in the face
• C. Client reports heartburn
• D. Client reports frequent urination

Correct answer: B

Rationale: The correct answer is B because facial swelling can indicate preeclampsia, a serious condition during pregnancy that requires immediate medical attention. Constipation (choice A), heartburn (choice C), and frequent urination (choice D) are common discomforts during pregnancy and are not typically indicative of a serious complication like preeclampsia at 32 weeks of gestation.

2. A nurse is providing discharge teaching to a client who is postpartum and has a prescription for methylergonovine. The nurse should instruct the client to report which of the following adverse effects?

• A. Headache
• B. Diarrhea
• C. Nausea
• D. Increased vaginal bleeding

Correct answer: A

Rationale: The correct answer is A: Headache. Methylergonovine can cause vasoconstriction, leading to headaches. It is important for the client to report this adverse effect to the provider as it may indicate a serious complication. Choices B, C, and D are incorrect because methylergonovine is not typically associated with diarrhea, nausea, or increased vaginal bleeding as common adverse effects.

3. A nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 70/min
• B. Vernix caseosa covering the skin
• C. Milia on the bridge of the nose
• D. Acrocyanosis of the extremities

Correct answer: A

Rationale: A respiratory rate of 70/min in a newborn is above the expected range and may indicate respiratory distress, which should be reported to the provider. Choice B, vernix caseosa covering the skin, is a normal finding in newborns and does not require reporting. Choice C, milia on the bridge of the nose, is also a common finding in newborns and does not require immediate reporting. Choice D, acrocyanosis of the extremities, is a common finding within the first few hours of life in newborns and typically resolves on its own, so it does not need to be reported.

4. 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.

5. A nurse is teaching a client who is at 20 weeks of gestation about the glucose tolerance test. Which of the following instructions should the nurse include?

• A. You should eat a low-carbohydrate diet for 3 days before the test.
• B. You will need to fast for 12 hours before the test.
• C. You should expect the test to take about 1 hour.
• D. You will need to limit fluid intake to water before the test.

Correct answer: C

Rationale: The correct answer is C. During a glucose tolerance test, the client is required to drink a glucose solution, and blood samples are taken at specific intervals, typically over a period of 1 to 3 hours. In this case, the nurse should inform the client to expect the test to take about 1 hour. Choices A, B, and D are incorrect because there is no specific instruction to eat a low-carbohydrate diet for 3 days before the test, fast for 12 hours before the test, or limit fluid intake to water before the test in a standard glucose tolerance test.

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