Nursing Elites

1. When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?

• A. Babinski
• B. Rooting
• C. Moro
• D. Stepping

Correct answer: B

Rationale: The correct answer is B: Rooting. The rooting reflex is crucial in newborns as it helps them locate the nipple for feeding. This reflex involves turning the head towards a stimulus that touches the cheek or mouth, aiding in the process of latching onto the breast for breastfeeding. The Babinski reflex is the fanning out and curling of the toes when the sole of the foot is stroked, the Moro reflex is the startle reflex in response to a sudden noise or movement, and the stepping reflex is the appearance of taking steps when an infant is held upright with feet touching a solid surface. Therefore, choices A, C, and D are incorrect as they do not play a direct role in promoting a newborn to latch during breastfeeding.

2. A client who is at 36 weeks of gestation and has a prescription for a nonstress test is being taught by a nurse. Which of the following statements should the nurse include in the teaching?

• A. You will receive IV fluid before this test.
• B. The procedure will take approximately 10 to 15 minutes.
• C. You will be offered orange juice to drink during the test.
• D. You will need to sign an informed consent form before each test.

Correct answer: C

Rationale: The correct statement the nurse should include in the teaching is that the client will be offered orange juice to drink during the nonstress test. This is because offering the client orange juice, or another beverage high in glucose, will help stimulate the fetus during the procedure, aiding in obtaining accurate results. Choice A is incorrect because IV fluid is not typically administered before a nonstress test. Choice B is incorrect as the procedure usually takes around 20 to 40 minutes. Choice D is incorrect as informed consent is typically obtained once for the procedure, not before each individual test.

3. A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

• A. Assess deep tendon reflexes every hour.
• B. Obtain a daily weight.
• C. Continuous fetal monitoring
• D. Ambulate twice daily

Correct answer: D

Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.

4. A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?

• A. Confirm the newborn's identification.
• B. Verify the newborn's identification.
• C. Administer vitamin K to the newborn.
• D. Determine obstetrical risk factors.

Correct answer: B

Rationale: When a newborn is transferred to the nursery, the first action the nurse should take is to verify the newborn's identification. This step is crucial for ensuring the correct care is provided to the right newborn, promoting patient safety and preventing errors. Administering vitamin K (Choice C) is important but should not be the first action. Determining obstetrical risk factors (Choice D) is not the priority when the newborn is transferred to the nursery. Confirming (Choice A) and verifying (Choice B) have similar meanings, but 'verify' is a more appropriate term in this context.

5. During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

• A. Maternal fever
• B. Fetal heart failure
• C. Maternal hypoglycemia
• D. Fetal head compression

Correct answer: A

Rationale: Maternal fever can lead to fetal tachycardia due to the transmission of maternal fever to the fetus. This can result in an increased fetal heart rate, making it the correct potential cause in this scenario. Fetal heart failure (choice B) would typically present with bradycardia rather than tachycardia, making it an incorrect choice. Maternal hypoglycemia (choice C) is more likely to cause fetal distress rather than tachycardia. Fetal head compression (choice D) may lead to decelerations in the fetal heart rate pattern, but not necessarily tachycardia.

Similar Questions