Nursing Elites

1. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

2. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which of the following recommendations should the nurse make?

• A. Limit sodium intake to 3,000 mg per day.
• B. Exercise for at least 30 minutes most days of the week.
• C. Drink no more than two alcoholic drinks per day.
• D. Increase fluid intake to at least 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: 'Exercise for at least 30 minutes most days of the week.' Regular exercise, especially aerobic activity, is known to help lower blood pressure and should be included in lifestyle changes for managing hypertension. Choice A is incorrect because the recommended sodium intake for individuals with hypertension is usually lower than 3,000 mg per day. Choice C is incorrect as it is advisable to limit alcohol intake to one drink per day for women and two drinks per day for men. Choice D is incorrect because increasing fluid intake to 3 liters per day may not be necessary and could be harmful in some cases, depending on the individual's health status.

3. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?

• A. Contraction frequency every 3 minutes
• B. Contraction duration of 100 seconds
• C. Fetal heart rate with moderate variability
• D. Fetal heart rate of 118/min

Correct answer: B

Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. Prolonged contractions may reduce oxygen supply to the fetus, putting it at risk. Discontinuing the oxytocin infusion is crucial to prevent adverse effects on both the mother and the fetus. The other options do not raise immediate concerns that would necessitate discontinuing the oxytocin infusion. Contraction frequency every 3 minutes is within a normal range. Fetal heart rate with moderate variability and a rate of 118/min are both reassuring signs of fetal well-being.

4. A client with hepatic encephalopathy is being cared for by a nurse. Which food selection indicates the client understands dietary teaching?

• A. A sandwich and milkshake
• B. Rice with black beans
• C. Cottage cheese and tuna lettuce
• D. Three-egg omelet with low-sodium ham

Correct answer: B

Rationale: For clients with hepatic encephalopathy, foods high in protein like cottage cheese and tuna should be avoided. Plant-based protein sources like beans are recommended due to their lower ammonia production during digestion. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they include high-protein or high-sodium foods that can worsen the condition of hepatic encephalopathy.

5. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?

• A. You do not need to have a full bladder for the procedure
• B. You will not receive magnesium sulfate before the procedure
• C. The procedure will take longer than 30 minutes to complete
• D. You should report if you experience any contractions after the procedure

Correct answer: D

Rationale: The correct statement to include in the teaching about amniocentesis is that the client should report if they experience any contractions after the procedure. This is crucial because contractions could indicate preterm labor or other complications following the amniocentesis. Choices A and B are incorrect as a full bladder is not required for the procedure, and magnesium sulfate is not typically given before an amniocentesis. Choice C is incorrect as the procedure usually takes about 20-30 minutes to complete.

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