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 client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. 1+ proteinuria
• B. Blood pressure 144/92 mm Hg
• C. Respiratory rate 22/min
• D. Urine output 20 mL/hr

Correct answer: D

Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.

3. A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?

• A. You should avoid lifting anything heavier than your newborn
• B. You should not lift anything heavier than your newborn
• C. You should wait 1 week before driving
• D. You can resume sexual activity in 2 weeks

Correct answer: B

Rationale: The correct instruction for a client who is postpartum and had a cesarean birth is to not lift anything heavier than her newborn. This precaution is crucial to prevent injury to the healing incision site and allow for proper recovery. Choice A is incorrect as it implies resuming abdominal exercises in 2 weeks, which may strain the incision area. Choice C is incorrect because the client should wait longer than 1 week before driving to ensure they can perform emergency maneuvers if needed. Choice D is incorrect as resuming sexual activity in 2 weeks may put strain on the healing tissues and increase the risk of complications.

4. 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.

5. 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.

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