Nursing Elites

1. A client who is postpartum reports abdominal cramping during breastfeeding. Which of the following actions should the nurse take?

• A. Administer ibuprofen
• B. Administer oxytocin
• C. Place a warm compress on the client's abdomen
• D. Assist the client to change positions

Correct answer: A

Rationale: Abdominal cramping during breastfeeding is common due to the release of oxytocin. Ibuprofen, an analgesic, is suitable for relieving discomfort. Administering oxytocin is unnecessary and may exacerbate the cramping. Placing a warm compress may not address the underlying cause of the cramping. Changing positions may provide temporary relief but does not address the cause of the cramping.

2. 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.

3. 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.

4. 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.

5. A client who is breastfeeding is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Breastfeed the newborn every 2 hours
• B. Offer both breasts at each feeding
• C. Supplement feedings with formula at night
• D. Expect the newborn to sleep through the night at 1 month

Correct answer: B

Rationale: The correct instruction for the nurse to include is to offer both breasts at each feeding. This practice helps ensure the baby receives hindmilk from both breasts, promoting adequate milk intake and stimulating milk production. Option A is incorrect as newborns should be breastfed on demand rather than on a strict schedule. Option C is inappropriate as it can interfere with establishing and maintaining a sufficient milk supply. Option D is inaccurate as newborns typically do not sleep through the night at one month; they need to feed frequently for proper growth and development.

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