Nursing Elites

1. A client in the first stage of labor is experiencing lower back pain and asks the nurse what can be done to relieve the pain. Which of the following interventions should the nurse suggest?

• A. Perform effleurage on the client's abdomen
• B. Apply counterpressure to the client's sacrum
• C. Provide a back massage with lavender oil
• D. Administer opioid analgesics

Correct answer: B

Rationale: Applying counterpressure to the sacrum can help alleviate lower back pain during labor by reducing pressure on the nerves. Effleurage on the abdomen, back massage with lavender oil, and administering opioid analgesics are not specifically targeted at relieving lower back pain, making them less effective interventions in this scenario.

2. A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should eat foods high in protein before bedtime.
• B. You should avoid consuming liquids with your meals.
• C. You should eat three large meals per day.
• D. You should consume caffeine to help with nausea.

Correct answer: B

Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.

3. A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?

• A. Tachycardia
• B. Hyperreflexia
• C. Respiratory rate of 10/min
• D. Polyuria

Correct answer: C

Rationale: Corrected Rationale: Magnesium sulfate can cause respiratory depression, leading to a decreased respiratory rate. A respiratory rate of 10/min is abnormally low and indicates magnesium toxicity. Tachycardia (Choice A) is not typically associated with magnesium toxicity. Hyperreflexia (Choice B) is a common sign of magnesium toxicity. Polyuria (Choice D) is not a typical finding of magnesium toxicity.

4. A nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 70/min
• B. Vernix caseosa covering the skin
• C. Milia on the bridge of the nose
• D. Acrocyanosis of the extremities

Correct answer: A

Rationale: A respiratory rate of 70/min in a newborn is above the expected range and may indicate respiratory distress, which should be reported to the provider. Choice B, vernix caseosa covering the skin, is a normal finding in newborns and does not require reporting. Choice C, milia on the bridge of the nose, is also a common finding in newborns and does not require immediate reporting. Choice D, acrocyanosis of the extremities, is a common finding within the first few hours of life in newborns and typically resolves on its own, so it does not need to be reported.

5. A newborn delivered at 41 weeks of gestation is showing signs of postmaturity. Which of the following findings is an indication of fetal postmaturity?

• A. Soft, flexible ear cartilage
• B. Smooth soles without creases
• C. Thin with loose skin
• D. Vernix caseosa covering the body

Correct answer: C

Rationale: The correct answer is C: 'Thin with loose skin.' Postmature newborns are typically thin with loose skin due to prolonged gestation. This may result from placental insufficiency, leading to reduced subcutaneous fat stores. Choices A, B, and D are incorrect. Soft, flexible ear cartilage (choice A) is a normal finding in newborns. Smooth soles without creases (choice B) are also typical in newborns. Vernix caseosa covering the body (choice D) is a protective, waxy coating found on newborns, which may be present in postmature infants as well.

Similar Questions