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 client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. 1+ proteinuria
• B. Blood pressure 144/92 mm Hg
• C. Respiratory rate 22/min
• D. Urine output 20 mL/hr

Correct answer: D

Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.

3. 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.

4. A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?

• A. Avoid sitting for long periods of time.
• B. Apply a cold pack to the perineal area for the first 24 hours.
• C. Use a sitz bath once per week.
• D. Begin Kegel exercises after the first week.

Correct answer: B

Rationale: The correct statement to include in the teaching is to apply a cold pack to the perineal area for the first 24 hours. This helps reduce swelling and promote comfort, aiding in the healing process after an episiotomy. Option A is incorrect as it does not provide specific guidance on managing postpartum recovery. Option C is incorrect because using a sitz bath once per week may not be frequent enough for proper wound care. Option D is incorrect because beginning Kegel exercises immediately after delivery can put excessive strain on the perineal area, potentially hindering healing.

5. A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?

• A. You should avoid lifting anything heavier than your newborn
• B. You should not lift anything heavier than your newborn
• C. You should wait 1 week before driving
• D. You can resume sexual activity in 2 weeks

Correct answer: B

Rationale: The correct instruction for a client who is postpartum and had a cesarean birth is to not lift anything heavier than her newborn. This precaution is crucial to prevent injury to the healing incision site and allow for proper recovery. Choice A is incorrect as it implies resuming abdominal exercises in 2 weeks, which may strain the incision area. Choice C is incorrect because the client should wait longer than 1 week before driving to ensure they can perform emergency maneuvers if needed. Choice D is incorrect as resuming sexual activity in 2 weeks may put strain on the healing tissues and increase the risk of complications.

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