Nursing Elites

1. 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.

2. 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.

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 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.

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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