Nursing Elites

1. A nurse is caring for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 120/80 mm Hg
• B. Weight gain of 0.9 kg (2 lb) in 1 week
• C. Urine output of 30 mL/hr
• D. Respiratory rate 16/min

Correct answer: B

Rationale: A weight gain of 0.9 kg (2 lb) in 1 week is an indication of fluid retention, which is concerning in a client with preeclampsia. This can be a sign of worsening condition requiring immediate medical attention. High blood pressure (option A) is expected in preeclampsia, a urine output of 30 mL/hr (option C) is decreased but not as urgent as the weight gain in this scenario, and a respiratory rate of 16/min (option D) is within normal limits.

2. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Proteinuria of 1+.
• B. Blood pressure 120/80 mm Hg.
• C. Respiratory rate of 18/min.
• D. Nonpitting ankle edema.

Correct answer: D

Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.

3. A client in active labor has ruptured membranes. What action should the nurse take?

• A. Apply a fetal heart rate monitor.
• B. Initiate fundal massage.
• C. Administer oxytocin IV.
• D. Insert an indwelling urinary catheter.

Correct answer: A

Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.

4. During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. The client's oxygen saturation is 95%
• B. The client's blood pressure is 110/70 mm Hg
• C. The client has a temperature of 36.8°C (98.2°F)
• D. The client's heart rate is 88/min

Correct answer: B

Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.

5. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?

• A. Apply zinc oxide ointment to the irritated area
• B. Wipe stool from the skin using store-bought baby wipes
• C. Apply talcum powder to the irritated area
• D. Apply a warm compress to the irritated area

Correct answer: A

Rationale: Correct answer: Applying zinc oxide ointment to the irritated area is the most appropriate action for diaper dermatitis. Zinc oxide is a barrier cream that helps protect the skin and promote healing. Choice B is incorrect because using store-bought baby wipes may contain chemicals or fragrances that can further irritate the skin. Choice C is incorrect as talcum powder can also worsen the condition by drying out the skin. Choice D is incorrect because a warm compress is not typically used for diaper dermatitis; it may provide relief for other conditions but is not the best option for diaper dermatitis.

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