Nursing Elites

1. 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.

2. A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?

• A. Contraction frequency of 2 minutes
• B. Contraction duration of 90 seconds
• C. Fetal heart rate of 150/min
• D. Urine output of 60 mL/hr

Correct answer: B

Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.

3. A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?

• A. You should avoid lifting anything heavier than your newborn
• B. You should not lift anything heavier than your newborn
• C. You should wait 1 week before driving
• D. You can resume sexual activity in 2 weeks

Correct answer: B

Rationale: The correct instruction for a client who is postpartum and had a cesarean birth is to not lift anything heavier than her newborn. This precaution is crucial to prevent injury to the healing incision site and allow for proper recovery. Choice A is incorrect as it implies resuming abdominal exercises in 2 weeks, which may strain the incision area. Choice C is incorrect because the client should wait longer than 1 week before driving to ensure they can perform emergency maneuvers if needed. Choice D is incorrect as resuming sexual activity in 2 weeks may put strain on the healing tissues and increase the risk of complications.

4. A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should eat foods high in protein before bedtime.
• B. You should avoid consuming liquids with your meals.
• C. You should eat three large meals per day.
• D. You should consume caffeine to help with nausea.

Correct answer: B

Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.

5. A nurse is assessing a client who is at 35 weeks of gestation and has suspected placenta previa. Which of the following findings should the nurse expect?

• A. Painless vaginal bleeding
• B. Severe abdominal pain
• C. Uterine contractions
• D. Increased fetal movement

Correct answer: A

Rationale: Correct. Placenta previa typically presents with painless vaginal bleeding as the placenta is located over or near the cervical opening. This bleeding occurs because the placental vessels are stretched and bleed easily. Severe abdominal pain (choice B) is not a typical finding in placenta previa. Uterine contractions (choice C) are more characteristic of preterm labor rather than placenta previa. Increased fetal movement (choice D) is not a specific finding associated with placenta previa.

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