Nursing Elites

1. A healthcare professional is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

• A. Hypertonia
• B. Increased feeding
• C. Hyperthermia
• D. Respiratory distress

Correct answer: D

Rationale: The correct answer is D, respiratory distress, as it is a clinical manifestation of hypoglycemia in newborns. Other signs of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. Hypertonia, increased feeding, and hyperthermia are not typically associated with hypoglycemia in newborns. Hypertonia is more indicative of neurological issues, increased feeding is not a common sign of hypoglycemia, and hyperthermia is not a typical symptom of low blood sugar.

2. During a weekly prenatal visit, a nurse is assessing a client at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 136/88 mm Hg
• B. Report of insomnia
• C. Weight gain of 2.2 kg (4.8 lb)
• D. Report of Braxton-Hicks contractions

Correct answer: C

Rationale: A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range for a client at 38 weeks of gestation and could indicate complications such as preeclampsia or gestational hypertension. Rapid weight gain at this stage requires immediate attention and should be reported to the provider for further evaluation and management. Choices A, B, and D are not the priority findings to report to the provider at this stage of gestation. Blood pressure of 136/88 mm Hg is within normal limits in pregnancy, insomnia is common in the third trimester, and Braxton-Hicks contractions are expected in the third trimester as the body prepares for labor.

3. A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

• A. Apply cold compresses to the affected extremity
• B. Massage the affected extremity
• C. Allow the client to ambulate
• D. Measure leg circumferences

Correct answer: D

Rationale: Measuring leg circumferences is crucial in monitoring for changes that may indicate worsening of thrombophlebitis, such as increased swelling or redness. This assessment helps in early detection of complications and timely intervention, reducing the risk of further health problems for the client. Applying cold compresses may worsen the condition by causing vasoconstriction. Massaging the affected extremity can dislodge a clot and lead to embolism. Allowing the client to ambulate may increase the risk of clot migration.

4. While caring for a newborn, a nurse auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

• A. Ask another nurse to verify the heart rate.
• B. Document this as an expected finding.
• C. Call the provider to further assess the newborn.
• D. Prepare the newborn for transport to the NICU.

Correct answer: B

Rationale: An apical heart rate of 130/min is within the expected range for a newborn. It is not necessary to seek verification from another nurse, call the provider for further assessment, or prepare for NICU transport based on this heart rate. Documenting the heart rate as an expected finding is the appropriate action in this situation as it falls within the normal range for a newborn's heart rate.

5. A healthcare provider is instructing a client who is taking an oral contraceptive about manifestations to report. Which of the following manifestations should the healthcare provider include?

• A. Reduced menstrual flow
• B. Breast tenderness
• C. Shortness of breath
• D. Increased appetite

Correct answer: C

Rationale: Shortness of breath is a symptom that can indicate a serious side effect of oral contraceptives, such as a potential blood clot in the lungs. This condition requires immediate medical attention to prevent complications. Choices A, B, and D are not typically associated with serious side effects of oral contraceptives and are considered normal or common side effects that do not require urgent medical attention.

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