Nursing Elites

1. A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

• A. Obtain a blood sample for a serum glucose level
• B. Feed the newborn immediately
• C. Administer 50 mL of dextrose solution IV
• D. Reassess the blood glucose level prior to the next feeding

Correct answer: D

Rationale: A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn. Reassessing the blood glucose level prior to the next feeding ensures ongoing monitoring without unnecessary intervention. Obtaining a blood sample for a serum glucose level (Choice A) is not necessary as the initial reading is normal. Feeding the newborn immediately (Choice B) may not be indicated and could lead to unnecessary interventions. Administering dextrose solution IV (Choice C) is not warranted as the glucose level is within the normal range and does not require immediate correction.

2. What is the typical sex chromosome pattern for females?

• A. XX
• B. XYY
• C. XY
• D. XXY

Correct answer: A

Rationale: The typical sex chromosome pattern for females is XX. Females have two X chromosomes, which is represented as XX. Choice B (XYY) is incorrect as it represents the sex chromosome pattern for males with an extra Y chromosome. Choice C (XY) is the sex chromosome pattern for males. Choice D (XXY) represents a genetic disorder known as Klinefelter syndrome, where males have an extra X chromosome.

3. A client who delivered a healthy newborn an hour ago asked the nurse when she can go home. Which information is most important for the nurse to provide the client?

• A. After the baby no longer demonstrates acrocyanosis
• B. After the baby receives the vitamin K injection
• C. When ambulating to avoid causing dizziness
• D. When there is no significant vaginal bleeding

Correct answer: D

Rationale: The most critical information for the nurse to provide the client is ensuring that there is no significant vaginal bleeding before discharge. This is vital to prevent complications such as postpartum hemorrhage. Options A, B, and C are important aspects of postpartum care, but assessing and managing vaginal bleeding takes precedence due to its potential seriousness.

4. A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What should the nurse do first?

• A. Push the call light for help
• B. Inspect the client's perineum
• C. Notify a healthcare provider
• D. Turn on the infant warmer

Correct answer: B

Rationale: Inspecting the client's perineum immediately is necessary to assess if the baby is being delivered, which would require urgent action. Pushing the call light for help (Choice A) may delay the assessment and immediate action needed. Notifying a healthcare provider (Choice C) might cause further delays, as the situation requires urgent attention. Turning on the infant warmer (Choice D) is not the priority; ensuring safe delivery and assessment of the baby's condition come first.

5. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

• A. Increase the intravenous fluid to 150 ml/hr.
• B. Call the healthcare provider.
• C. Encourage the client to void.
• D. Administer ibuprofen 800 milligrams by mouth.

Correct answer: C

Rationale: Encouraging the client to void is the priority action in this scenario. A distended bladder can prevent the uterus from contracting properly, leading to increased bleeding and a high uterine fundus. By encouraging the client to void, the nurse can help the uterus contract effectively, reducing bleeding. Increasing intravenous fluids or administering ibuprofen would not address the immediate concern of a distended bladder affecting uterine contraction. While it may be necessary to involve the healthcare provider, addressing the bladder distention promptly is crucial to prevent further complications.

Similar Questions