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 nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?

• A. Contraction frequency of every 3 minutes
• B. Contraction duration of 80 seconds
• C. Late decelerations in the fetal heart rate
• D. Urine output of 50 mL/hr

Correct answer: C

Rationale: Late decelerations in the fetal heart rate require immediate intervention as they can indicate fetal distress due to uteroplacental insufficiency. This finding suggests a compromised blood flow to the fetus, which can lead to serious complications if not addressed promptly. Contraction frequency and duration are important to monitor but do not necessitate immediate intervention unless they are causing fetal distress. Urine output of 50 mL/hr is within the normal range for a client in labor and does not require immediate intervention.

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 healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?

• A. Respiratory rate 50/min
• B. Blood glucose 30 mg/dL
• C. Blood pressure 60/40 mm Hg
• D. Heart rate 140/min

Correct answer: B

Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.

5. A client in the first trimester of pregnancy who is experiencing nausea is receiving teaching from a nurse. Which of the following instructions should the nurse include in the teaching?

• A. Drink water with meals
• B. Consume small, frequent meals
• C. Eat high-fat foods
• D. Lie down after eating

Correct answer: B

Rationale: The correct instruction for a client in the first trimester of pregnancy experiencing nausea is to consume small, frequent meals. This helps alleviate nausea by preventing an empty stomach and maintaining stable blood sugar levels. Drinking water with meals can sometimes exacerbate nausea, especially in the case of morning sickness. Eating high-fat foods can be heavy on the stomach and worsen nausea. Lying down after eating can lead to reflux and is not recommended, especially for pregnant individuals experiencing nausea.

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