Nursing Elites

1. A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?

• A. Postpartum fatigue
• B. Postpartum psychosis
• C. Letting-go phase
• D. Postpartum blues

Correct answer: D

Rationale: The correct answer is D, Postpartum blues. Postpartum blues, also known as baby blues, are common after childbirth and are characterized by symptoms like tearfulness, insomnia, lack of appetite, and a feeling of letdown. This condition is typically self-limiting and resolves without specific treatment. Postpartum fatigue (choice A) refers to extreme tiredness after childbirth but does not typically include symptoms like tearfulness and insomnia. Postpartum psychosis (choice B) is a severe condition that includes symptoms such as hallucinations and delusions, which are not present in the scenario. The letting-go phase (choice C) does not represent a specific postpartum condition related to the symptoms described.

2. A healthcare professional is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

• A. Hypertonia
• B. Increased feeding
• C. Hyperthermia
• D. Respiratory distress

Correct answer: D

Rationale: The correct answer is D, respiratory distress, as it is a clinical manifestation of hypoglycemia in newborns. Other signs of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. Hypertonia, increased feeding, and hyperthermia are not typically associated with hypoglycemia in newborns. Hypertonia is more indicative of neurological issues, increased feeding is not a common sign of hypoglycemia, and hyperthermia is not a typical symptom of low blood sugar.

3. When should a provider order a maternal serum alpha-fetoprotein (MSAFP) screening for pregnant clients?

• A. A client who has mitral valve prolapse
• B. A client who has been exposed to AIDS
• C. All pregnant clients
• D. A client who has a history of preterm labor

Correct answer: C

Rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is recommended for all pregnant clients to assess the risk of neural tube defects. It is a routine screening test used to detect increased levels of alpha-fetoprotein in maternal blood, which may indicate a higher risk for conditions such as neural tube defects in the developing fetus. Therefore, all pregnant clients, regardless of their medical history or risk factors, should undergo MSAFP screening as part of routine prenatal care. Choices A, B, and D are incorrect because the MSAFP screening is not specific to certain medical conditions or histories; it is a standard screening procedure for all pregnant individuals to evaluate neural tube defect risk in the fetus.

4. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?

• A. Evidence of a possible vaginal hematoma
• B. An indication of a cervical or perineal laceration
• C. A normal postpartum discharge of lochia
• D. Abnormally excessive lochia rubra flow

Correct answer: C

Rationale: The nurse should interpret this data as a normal postpartum discharge of lochia. Lochia is the normal vaginal discharge after childbirth, and the gush of dark red blood upon ambulation is typical due to the pooling of blood in the vagina when lying down, which is then released upon standing. The firm, midline uterus at the level of the umbilicus indicates normal involution of the uterus postpartum. Therefore, this scenario is consistent with the expected postpartum physiological changes rather than complications like hematoma, lacerations, or abnormal excessive bleeding. Choices A, B, and D are incorrect because the described findings are more indicative of normal postpartum processes rather than complications such as vaginal hematoma, lacerations, or excessive bleeding.

5. A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

• A. Heart rate 168/min
• B. Respiratory rate 18/min
• C. Tremors
• D. Fine crackles

Correct answer: B

Rationale: A newborn's respiratory rate can vary between 20 to 100 breaths per minute during the initial phase after birth. A respiratory rate as low as 18 breaths per minute at this early stage requires immediate nursing intervention. This finding necessitates further assessment to ensure adequate oxygenation and respiratory function. The other options, heart rate of 168/min, tremors, and fine crackles, are within normal limits for a full-term newborn and do not require immediate intervention.

Similar Questions