Nursing Elites

1. A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

• A. 22/min
• B. 48/min
• C. 100/min
• D. 110/min

Correct answer: B

Rationale: The expected respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48 breaths per minute falls within this range, indicating normal respiratory function for a newborn. Choice A (22/min) is below the expected range, Choices C (100/min) and D (110/min) are above the expected range for a newborn's respiratory rate.

2. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

• A. Monitor the client's blood pressure every hour.
• B. Restrict the total hourly intake to 200 mL.
• C. Monitor the FHR continuously.
• D. Administer protamine sulfate for manifestations of toxicity.

Correct answer: C

Rationale: The correct answer is C. When a client with preeclampsia is receiving magnesium sulfate via continuous IV infusion, it is crucial to monitor the fetal heart rate (FHR) continuously. Magnesium sulfate is given to prevent seizures and is considered a high-alert medication that requires close monitoring, especially of FHR and uterine contractions. Monitoring the client's blood pressure every hour, as in choice A, is important but not as crucial as continuous FHR monitoring. Restricting the total hourly intake to 200 mL, as in choice B, is not a relevant intervention for a client receiving magnesium sulfate. Administering protamine sulfate for manifestations of toxicity, as in choice D, is incorrect as protamine sulfate is not the antidote for magnesium sulfate toxicity.

3. A healthcare professional is assessing four newborns. Which of the following findings should the professional report to the provider?

• A. A newborn who is 26 hours old and has erythema toxicum on their face
• B. A newborn who is 32 hours old and has not passed meconium stool
• C. A newborn who is 12 hours old and has pink-tinged urine
• D. A newborn who is 18 hours old and has an axillary temperature of 37.7° C (99.9° F)

Correct answer: D

Rationale: An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the healthcare professional should report this finding to the provider for further evaluation and management to rule out sepsis. Choices A, B, and C are within the expected range of normal findings for newborns. Erythema toxicum is a common and benign rash in newborns, not requiring immediate reporting. Not passing meconium stool within the first 24-48 hours can be normal, and pink-tinged urine can be due to uric acid crystals excretion, which is also common in newborns.

4. When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?

• A. I am glad I can have my morning coffee.
• B. I should take folic acid to increase my milk supply.
• C. I will continue adding 330 calories per day to my diet.
• D. I will continue my calcium supplements because I don't like milk.

Correct answer: D

Rationale: The correct answer is D. Clients who do not like milk should continue taking calcium supplements to ensure they meet their increased calcium needs while breastfeeding. Calcium is essential for bone health, and during breastfeeding, the mother's calcium requirements are higher. While caffeine in coffee can be consumed in moderation, folic acid does not directly impact milk supply, and the additional 330 calories per day are recommended but not the focus of this question.

5. When caring for clients in a prenatal clinic, a nurse should report which client's weight gain to the provider?

• A. 1.8 kg (4 lb) weight gain in the first trimester
• B. 3.6 kg (8 lb) weight gain in the first trimester
• C. 6.8 kg (15 lb) weight gain in the second trimester
• D. 11.3 kg (25 lb) weight gain in the third trimester

Correct answer: B

Rationale: A weight gain of 3.6 kg (8 lb) in the first trimester is excessive and should be reported to the provider for further evaluation. Excessive weight gain in the first trimester can be a sign of potential issues that need monitoring and intervention to ensure the well-being of both the mother and the baby. Choices A, C, and D represent weight gains that are within normal ranges for the respective trimesters and do not raise immediate concerns for reporting to the provider.

Similar Questions