Nursing Elites

1. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?

• A. Caput succedaneum
• B. Jaundice
• C. Acrocyanosis
• D. Overlapping cranial sutures

Correct answer: B

Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.

2. A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 10/min
• B. Urine output of 30 mL/hr
• C. Deep tendon reflexes 2+
• D. Client reports feeling warm

Correct answer: A

Rationale: A respiratory rate of 10/min is significantly low and indicates potential magnesium toxicity, which can lead to respiratory depression. This finding should be reported to the provider immediately for further evaluation and management. Urine output of 30 mL/hr is within the expected range during magnesium sulfate therapy and does not require immediate reporting. Deep tendon reflexes 2+ are a normal finding and do not indicate any immediate concerns. The client reporting feeling warm is a common side effect of magnesium sulfate and does not require immediate reporting unless accompanied by other symptoms.

3. 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.

4. A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?

• A. This medication will help prevent contractions.
• B. This medication will reduce my baby's risk of respiratory distress.
• C. This medication will prevent early labor.
• D. This medication will increase my baby's weight.

Correct answer: B

Rationale: Correct answer: Option B. Betamethasone is a glucocorticoid used to promote fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Option A is incorrect because betamethasone does not prevent contractions. Option C is incorrect as betamethasone does not prevent early labor but helps improve fetal lung development. Option D is incorrect as betamethasone does not increase the baby's weight.

5. A client who is breastfeeding is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Breastfeed the newborn every 2 hours
• B. Offer both breasts at each feeding
• C. Supplement feedings with formula at night
• D. Expect the newborn to sleep through the night at 1 month

Correct answer: B

Rationale: The correct instruction for the nurse to include is to offer both breasts at each feeding. This practice helps ensure the baby receives hindmilk from both breasts, promoting adequate milk intake and stimulating milk production. Option A is incorrect as newborns should be breastfed on demand rather than on a strict schedule. Option C is inappropriate as it can interfere with establishing and maintaining a sufficient milk supply. Option D is inaccurate as newborns typically do not sleep through the night at one month; they need to feed frequently for proper growth and development.

Similar Questions