Nursing Elites

1. 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.

2. 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.

3. 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.

4. A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?

• A. You should expect to feel your baby move at 12 weeks.
• B. You will need to increase your calcium intake during pregnancy.
• C. You should avoid exercise during the second trimester.
• D. You will need to limit your intake of folic acid during pregnancy.

Correct answer: B

Rationale: The correct answer is B. Calcium intake is crucial during pregnancy to support fetal bone development. The nurse should educate the client to increase their calcium intake. Choice A is incorrect because fetal movements are usually felt around 18-25 weeks, not at 12 weeks. Choice C is incorrect as exercise is generally encouraged during pregnancy, including the second trimester, as long as it is not high-impact or risky. Choice D is incorrect as folic acid intake is essential during pregnancy to prevent neural tube defects, and pregnant individuals are usually advised to increase their folic acid intake.

5. A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 80/50 mm Hg
• B. Uterine contractions
• C. Urine output 150 mL in 2 hours
• D. Client reports cramping

Correct answer: A

Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.

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