Nursing Elites

1. A client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?

• A. Fetal heart rate 100/min
• B. Weakened uterine contractions
• C. Enhanced production of fetal lung surfactant
• D. Maternal blood glucose 63 mg/dL

Correct answer: B

Rationale: Terbutaline is a tocolytic medication that works by relaxing the uterine muscles, leading to weakened uterine contractions. This effect helps to prevent preterm labor. Therefore, the nurse should expect weakened uterine contractions in a client who has received terbutaline at 28 weeks of gestation. Choices A, C, and D are incorrect. Terbutaline administration would not directly affect the fetal heart rate, enhance fetal lung surfactant production, or cause maternal hypoglycemia.

2. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

• A. Monitor the client's blood pressure every hour.
• B. Restrict the total hourly intake to 200 mL.
• C. Monitor the FHR continuously.
• D. Administer protamine sulfate for manifestations of toxicity.

Correct answer: C

Rationale: The correct answer is C. When a client with preeclampsia is receiving magnesium sulfate via continuous IV infusion, it is crucial to monitor the fetal heart rate (FHR) continuously. Magnesium sulfate is given to prevent seizures and is considered a high-alert medication that requires close monitoring, especially of FHR and uterine contractions. Monitoring the client's blood pressure every hour, as in choice A, is important but not as crucial as continuous FHR monitoring. Restricting the total hourly intake to 200 mL, as in choice B, is not a relevant intervention for a client receiving magnesium sulfate. Administering protamine sulfate for manifestations of toxicity, as in choice D, is incorrect as protamine sulfate is not the antidote for magnesium sulfate toxicity.

3. When checking for the Moro reflex in a newborn, what action should the nurse take?

• A. Hold the newborn vertically under arms and allow one foot to touch the table.
• B. Stimulate the pads of the newborn's hands with stroking or massage.
• C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
• D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.

Correct answer: D

Rationale: The correct action to check for the Moro reflex in a newborn is to hold the newborn in a semi-sitting position and then allow the newborn's head and trunk to fall backward. The Moro reflex is elicited by a sudden loss of support or a loud noise. The normal response involves symmetrical abduction and extension of the arms, followed by their return to the midline in an embracing motion. Choices A, B, and C do not describe the correct method for assessing the Moro reflex and are therefore incorrect.

4. When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?

• A. I am glad I can have my morning coffee.
• B. I should take folic acid to increase my milk supply.
• C. I will continue adding 330 calories per day to my diet.
• D. I will continue my calcium supplements because I don't like milk.

Correct answer: D

Rationale: The correct answer is D. Clients who do not like milk should continue taking calcium supplements to ensure they meet their increased calcium needs while breastfeeding. Calcium is essential for bone health, and during breastfeeding, the mother's calcium requirements are higher. While caffeine in coffee can be consumed in moderation, folic acid does not directly impact milk supply, and the additional 330 calories per day are recommended but not the focus of this question.

5. A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?

• A. Using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and STIs.
• B. A diaphragm should be removed 2 hours after intercourse.
• C. Oral contraceptives can worsen a case of acne.
• D. A contraceptive patch is replaced once a month.

Correct answer: A

Rationale: The correct answer is A because using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and sexually transmitted infections (STIs). This statement demonstrates the client's understanding of the importance of proper condom use to maximize protection. Choice B is incorrect because a diaphragm should be left in place for at least 6 hours after intercourse to ensure contraceptive effectiveness. Choice C is incorrect as oral contraceptives are known to improve acne in some cases. Choice D is incorrect because a contraceptive patch is typically replaced weekly, not monthly.

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