Nursing Elites

1. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

• A. Hyporeactivity
• B. Excessive high-pitched cry
• C. Acrocyanosis
• D. Respiratory rate of 50/min

Correct answer: B

Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Neonates with neonatal abstinence syndrome often display irritability, tremors, and feeding difficulties. Hyporeactivity, acrocyanosis, and a respiratory rate of 50/min are not typical manifestations of neonatal abstinence syndrome. Hyporeactivity is more associated with conditions like hypothyroidism or sepsis, acrocyanosis is a common finding in newborns due to immature peripheral circulation, and a respiratory rate of 50/min is within the normal range for a newborn.

2. A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?

• A. History of anxiety
• B. Socioeconomic status
• C. Hormonal changes with a rapid decline in estrogen and progesterone
• D. Support from family members

Correct answer: C

Rationale: Postpartum depression can be triggered by various factors, but one of the strongest predictors is a rapid drop in estrogen and progesterone levels following childbirth. These hormonal changes can affect mood regulation, making some women more vulnerable to depression during the postpartum period. Choices A, B, and D are not direct risk factors associated with postpartum depression. While a history of anxiety may contribute, it is not as directly linked to the hormonal changes that occur postpartum. Socioeconomic status and support from family members may influence the overall well-being of the mother but are not specific risk factors for postpartum depression.

3. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

5. A nurse is assessing a client who is 12 hours post-surgery. The client has an indwelling urinary catheter, and the nurse notes a urinary output of 15 mL/hr. Which of the following interventions should the nurse implement first?

• A. Irrigate the catheter
• B. Assess the patency of the catheter
• C. Increase the IV fluid rate
• D. Notify the provider

Correct answer: B

Rationale: The nurse should first assess the patency of the catheter to ensure that the low output is not caused by a blockage. It is crucial to rule out any obstructions before considering other interventions. Irrigating the catheter without verifying patency may worsen the situation if there is a blockage. Increasing IV fluid rate may not address the underlying issue if the problem lies with the catheter. Notifying the provider should come after ensuring the catheter's patency.

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