Nursing Elites

1. A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 10/min
• B. Urine output of 30 mL/hr
• C. Deep tendon reflexes 2+
• D. Client reports feeling warm

Correct answer: A

Rationale: A respiratory rate of 10/min is significantly low and indicates potential magnesium toxicity, which can lead to respiratory depression. This finding should be reported to the provider immediately for further evaluation and management. Urine output of 30 mL/hr is within the expected range during magnesium sulfate therapy and does not require immediate reporting. Deep tendon reflexes 2+ are a normal finding and do not indicate any immediate concerns. The client reporting feeling warm is a common side effect of magnesium sulfate and does not require immediate reporting unless accompanied by other symptoms.

2. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?

• A. Caput succedaneum
• B. Jaundice
• C. Acrocyanosis
• D. Overlapping cranial sutures

Correct answer: B

Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.

3. A nurse is assessing a client who is at 35 weeks of gestation and has suspected placenta previa. Which of the following findings should the nurse expect?

• A. Painless vaginal bleeding
• B. Severe abdominal pain
• C. Uterine contractions
• D. Increased fetal movement

Correct answer: A

Rationale: Correct. Placenta previa typically presents with painless vaginal bleeding as the placenta is located over or near the cervical opening. This bleeding occurs because the placental vessels are stretched and bleed easily. Severe abdominal pain (choice B) is not a typical finding in placenta previa. Uterine contractions (choice C) are more characteristic of preterm labor rather than placenta previa. Increased fetal movement (choice D) is not a specific finding associated with placenta previa.

4. 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.

5. A nurse is preparing to administer terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client is an indication that the medication is effective?

• A. I feel like my contractions are getting stronger.
• B. I feel like my heart is racing.
• C. My baby is moving less than before.
• D. My contractions have stopped.

Correct answer: D

Rationale: Terbutaline is a tocolytic medication used to stop uterine contractions. The client stating that the contractions have stopped indicates that the medication is effective. Choices A, B, and C are incorrect because feeling stronger contractions, a racing heart, or decreased fetal movement are not signs of terbutaline effectiveness in managing preterm labor.

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