Nursing Elites

1. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?

• A. Feed the newborn on demand
• B. Apply warm compresses to the breast before feeding
• C. Massage the breast after feedings
• D. Ensure the newborn empties one breast before switching to the other

Correct answer: D

Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.

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 nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 160/min
• B. Axillary temperature 36.8°C (98.2°F)
• C. Yellow-tinged skin
• D. Respiratory rate 42/min

Correct answer: C

Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.

4. 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.

5. A nurse is preparing to administer terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client is an indication that the medication is effective?

• A. I feel like my contractions are getting stronger.
• B. I feel like my heart is racing.
• C. My baby is moving less than before.
• D. My contractions have stopped.

Correct answer: D

Rationale: Terbutaline is a tocolytic medication used to stop uterine contractions. The client stating that the contractions have stopped indicates that the medication is effective. Choices A, B, and C are incorrect because feeling stronger contractions, a racing heart, or decreased fetal movement are not signs of terbutaline effectiveness in managing preterm labor.

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