Nursing Elites

1. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

• A. Evaluate the firmness of the uterus.
• B. Initiate oxygen therapy via a non-rebreather mask.
• C. Administer oxytocin infusion.
• D. Obtain a type and crossmatch.

Correct answer: A

Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

2. A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?

• A. Dark green leafy vegetables
• B. Deep red or orange vegetables
• C. White bread and rice
• D. Meat, poultry, and fish

Correct answer: A

Rationale: Dark green leafy vegetables are rich in calcium, making them an excellent alternative source for individuals who dislike or cannot consume dairy products. Calcium is crucial for bone health, particularly during pregnancy, to support the developing fetus and maintain the mother's bone strength. Therefore, recommending dark green leafy vegetables ensures the client receives an adequate intake of calcium despite not liking milk. Choice B, deep red or orange vegetables, are not typically high in calcium. Choice C, white bread and rice, are not significant sources of calcium. Choice D, meat, poultry, and fish, are good sources of protein but do not provide as much calcium as dark green leafy vegetables.

3. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

• A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
• B. A fourth-degree episiotomy extends into the rectal area and is not recommended
• C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
• D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

4. While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?

• A. Conjunctivitis
• B. Bronze skin discoloration
• C. Sunken fontanels
• D. Maculopapular skin rash

Correct answer: C

Rationale: Sunken fontanels should be prioritized for reporting as they indicate dehydration, which is a critical concern in infants undergoing phototherapy. Dehydration can lead to serious complications, making it essential for the nurse to promptly inform the charge nurse for appropriate intervention and management. Conjunctivitis, bronze skin discoloration, and maculopapular skin rash are important findings to note, but in this scenario, sunken fontanels take precedence due to the potential severity of dehydration in infants.

5. When developing an educational program for adolescents about nutrition during the third trimester of pregnancy, which of the following statements should be included?

• A. Consume three to four servings of dairy each day.
• B. Increase daily caloric intake by 600 to 700 calories.
• C. Limit daily sodium intake to less than 1 gram.
• D. Increase protein intake to 40 to 50 grams per day.

Correct answer: A

Rationale: The correct statement to include when developing an educational program for adolescents about nutrition during the third trimester of pregnancy is to consume three to four servings of dairy each day. Adequate calcium intake is crucial for bone development during pregnancy and helps prevent complications related to inadequate calcium intake. Increasing daily caloric intake by 600 to 700 calories (Choice B) is not necessary during the third trimester; excessive caloric intake can lead to unnecessary weight gain. Limiting daily sodium intake to less than 1 gram (Choice C) is not suitable during pregnancy, as some sodium intake is necessary for maintaining fluid balance. Increasing protein intake to 40 to 50 grams per day (Choice D) is important during pregnancy, but the emphasis in this case should be on calcium from dairy sources for bone development.

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