Nursing Elites

1. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?

• A. Continue to monitor the fetal heart rate
• B. Reposition the client
• C. Administer oxygen via face mask
• D. Increase the rate of the IV fluids

Correct answer: A

Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.

2. A client at 37 weeks of gestation is scheduled for a nonstress test. What information should the nurse include?

• A. You will be given oxytocin during the test.
• B. You will need to fast for 12 hours before the test.
• C. You will need to drink orange juice before the test.
• D. You will need to have a full bladder during the test.

Correct answer: C

Rationale: The correct answer is C. Drinking orange juice before the nonstress test can increase fetal movement, which is essential for an accurate reading. Choice A is incorrect because oxytocin is not typically administered during a nonstress test. Choice B is incorrect as fasting is not required before this test. Choice D is incorrect as a full bladder is not necessary for a nonstress test.

3. A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 160/min
• B. Axillary temperature 36.8°C (98.2°F)
• C. Yellow-tinged skin
• D. Respiratory rate 42/min

Correct answer: C

Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.

4. A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?

• A. Tachycardia
• B. Hyperreflexia
• C. Respiratory rate of 10/min
• D. Polyuria

Correct answer: C

Rationale: Corrected Rationale: Magnesium sulfate can cause respiratory depression, leading to a decreased respiratory rate. A respiratory rate of 10/min is abnormally low and indicates magnesium toxicity. Tachycardia (Choice A) is not typically associated with magnesium toxicity. Hyperreflexia (Choice B) is a common sign of magnesium toxicity. Polyuria (Choice D) is not a typical finding of magnesium toxicity.

5. A client who is postpartum reports abdominal cramping during breastfeeding. Which of the following actions should the nurse take?

• A. Administer ibuprofen
• B. Administer oxytocin
• C. Place a warm compress on the client's abdomen
• D. Assist the client to change positions

Correct answer: A

Rationale: Abdominal cramping during breastfeeding is common due to the release of oxytocin. Ibuprofen, an analgesic, is suitable for relieving discomfort. Administering oxytocin is unnecessary and may exacerbate the cramping. Placing a warm compress may not address the underlying cause of the cramping. Changing positions may provide temporary relief but does not address the cause of the cramping.

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