Nursing Elites

1. A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?

• A. Instruct the client to perform rapid, shallow breathing
• B. Prepare the client for an emergency cesarean birth
• C. Have the client perform pelvic tilts during contractions
• D. Apply counterpressure to the client's sacrum

Correct answer: A

Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.

2. 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.

3. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?

• A. Feed the newborn on demand
• B. Apply warm compresses to the breast before feeding
• C. Massage the breast after feedings
• D. Ensure the newborn empties one breast before switching to the other

Correct answer: D

Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.

4. 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.

5. A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?

• A. Hyperbilirubinemia
• B. Hypoglycemia
• C. Hypercalcemia
• D. Hypothermia

Correct answer: B

Rationale: Newborns who are large for gestational age (LGA) are at risk for hypoglycemia due to increased insulin production. Hyperbilirubinemia (Choice A) is more commonly associated with ABO or Rh incompatibility. Hypercalcemia (Choice C) is not a common finding in LGA newborns. Hypothermia (Choice D) may occur in newborns who are small for gestational age (SGA) due to a lack of subcutaneous fat for insulation, but it is not typically associated with LGA newborns.

Similar Questions