Nursing Elites

1. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

• A. The newborn will have decreased muscle tone.
• B. The newborn will have a continuous high-pitched cry.
• C. The newborn will sleep for 2 to 3 hours after a feeding.
• D. The newborn will have mild tremors when disturbed.

Correct answer: B

Rationale: The correct answer is B. A continuous high-pitched cry is a characteristic sign of neonatal abstinence syndrome, indicating withdrawal from drugs. Choices A, C, and D are incorrect because decreased muscle tone, sleeping for 2 to 3 hours after a feeding, and mild tremors when disturbed are not specific indicators of neonatal abstinence syndrome.

2. A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

• A. Place the client in a side-lying position.
• B. Assist the client to the bathroom to void.
• C. Obtain a prescription for IV oxytocin.
• D. Administer methylergonovine.

Correct answer: B

Rationale: In this scenario, the client's fundus findings indicate a distended bladder, which can lead to uterine atony. Assisting the client to the bathroom to void is essential as a distended bladder can inhibit the uterus from contracting normally. This action can help the uterus contract effectively and prevent complications such as postpartum hemorrhage. Placing the client in a side-lying position, obtaining a prescription for IV oxytocin, or administering methylergonovine are not the priority actions in this situation. Placing the client in a side-lying position might be indicated for fundal displacement, but it is not the priority here. Obtaining a prescription for IV oxytocin and administering methylergonovine are interventions for managing uterine atony, which is not the primary issue in this case; the priority is addressing the distended bladder.

3. A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?

• A. Assist the client into the left-lateral position
• B. Apply a fetal scalp electrode
• C. Insert an IV catheter
• D. Perform a vaginal exam

Correct answer: A

Rationale: Late decelerations indicate uteroplacental insufficiency. The initial action should be to assist the client into the left-lateral position to optimize maternal blood flow and oxygenation to the fetus, thereby improving uteroplacental blood flow and fetal oxygenation. This position helps reduce pressure on the vena cava, enhancing blood return to the heart and improving circulation to the placenta. Applying a fetal scalp electrode (Choice B) is not the first action indicated for late decelerations. Inserting an IV catheter (Choice C) and performing a vaginal exam (Choice D) are not primary interventions for addressing late decelerations related to uteroplacental insufficiency.

4. During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?

• A. Leukorrhea
• B. Supine hypotension
• C. Periodic numbness of the fingers
• D. Decreased urine output

Correct answer: D

Rationale: During pregnancy, decreased urine output can be indicative of decreased renal perfusion and impaired fetal well-being. It can also be a sign of preeclampsia when associated with symptoms like increased blood pressure, proteinuria, and decreased fetal activity. Therefore, the nurse should promptly report this finding to the healthcare provider for further evaluation and management. Leukorrhea is a common finding in pregnancy and not typically concerning. Supine hypotension and periodic numbness of the fingers can be managed by changing positions or adjusting posture and are not as urgent as decreased urine output in this context.

5. A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

• A. Prepare for a cesarean birth.
• B. Assist the client to an upright position.
• C. Prepare for an immediate vaginal delivery.
• D. Assist the client to turn onto her side.

Correct answer: D

Rationale: Turning the client onto her side is the appropriate nursing intervention in this scenario. This position can help improve blood pressure by enhancing venous return, which may aid in increasing perfusion to vital organs. It can also alleviate pressure on the inferior vena cava, promoting better circulation and supporting blood pressure stabilization during labor. Choices A, B, and C are incorrect. A cesarean birth is not indicated based on the information provided. Assisting the client to an upright position may worsen her blood pressure due to decreased venous return. Lastly, there is no indication for an immediate vaginal delivery solely based on the client's blood pressure reading.

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