Nursing Elites

1. A healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?

• A. Respiratory rate 50/min
• B. Blood glucose 30 mg/dL
• C. Blood pressure 60/40 mm Hg
• D. Heart rate 140/min

Correct answer: B

Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.

2. A nurse is providing discharge teaching to a client who is postpartum and has a prescription for methylergonovine. The nurse should instruct the client to report which of the following adverse effects?

• A. Headache
• B. Diarrhea
• C. Nausea
• D. Increased vaginal bleeding

Correct answer: A

Rationale: The correct answer is A: Headache. Methylergonovine can cause vasoconstriction, leading to headaches. It is important for the client to report this adverse effect to the provider as it may indicate a serious complication. Choices B, C, and D are incorrect because methylergonovine is not typically associated with diarrhea, nausea, or increased vaginal bleeding as common adverse effects.

3. A nurse is preparing to administer terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client is an indication that the medication is effective?

• A. I feel like my contractions are getting stronger.
• B. I feel like my heart is racing.
• C. My baby is moving less than before.
• D. My contractions have stopped.

Correct answer: D

Rationale: Terbutaline is a tocolytic medication used to stop uterine contractions. The client stating that the contractions have stopped indicates that the medication is effective. Choices A, B, and C are incorrect because feeling stronger contractions, a racing heart, or decreased fetal movement are not signs of terbutaline effectiveness in managing preterm labor.

4. 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.

5. A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. 1+ proteinuria
• B. Blood pressure 144/92 mm Hg
• C. Respiratory rate 22/min
• D. Urine output 20 mL/hr

Correct answer: D

Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.

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