Nursing Elites

1. A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?

• A. Confirm the newborn's identification.
• B. Verify the newborn's identification.
• C. Administer vitamin K to the newborn.
• D. Determine obstetrical risk factors.

Correct answer: B

Rationale: When a newborn is transferred to the nursery, the first action the nurse should take is to verify the newborn's identification. This step is crucial for ensuring the correct care is provided to the right newborn, promoting patient safety and preventing errors. Administering vitamin K (Choice C) is important but should not be the first action. Determining obstetrical risk factors (Choice D) is not the priority when the newborn is transferred to the nursery. Confirming (Choice A) and verifying (Choice B) have similar meanings, but 'verify' is a more appropriate term in this context.

2. A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?

• A. I will inform the provider that you are having these feelings.
• B. It is normal to have these feelings during the first few months of pregnancy.
• C. You should be happy that you are going to bring new life into the world.
• D. I am going to make an appointment with the counselor for you to discuss these thoughts.

Correct answer: B

Rationale: During the first few months of pregnancy, it is common for individuals to experience mixed feelings due to hormonal changes and the significant life adjustments that come with pregnancy. The nurse's response should acknowledge the client's feelings as normal and provide reassurance rather than dismissive or directive statements. By acknowledging the normalcy of these emotions, the nurse validates the client's experience and offers support during this critical time. Choices A, C, and D are less appropriate. Choice A focuses on informing the provider without addressing the client's emotions directly. Choice C disregards the client's current feelings and imposes a specific emotional response. Choice D jumps to scheduling a counseling appointment without first acknowledging the client's emotions or providing immediate support and validation.

3. A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

• A. The client's room number
• B. The client's telephone number
• C. The client's birth date
• D. The client's medical record number

Correct answer: A

Rationale: The correct answer is A. Using the client's room number as a secondary identifier is not an appropriate method for client identification in healthcare settings. It can lead to confusion and potential errors, especially in a busy environment like a postpartum unit. Room numbers are not unique to individual patients and can change frequently. Instead, healthcare providers should use more reliable and specific identifiers like the client's name, medical record number, or date of birth to ensure accurate identification and safe administration of medications. Choices B, C, and D are more appropriate secondary identifiers for client identification as they are more specific and less prone to errors than room numbers.

4. A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?

• A. Postpartum fatigue
• B. Postpartum psychosis
• C. Letting-go phase
• D. Postpartum blues

Correct answer: D

Rationale: The correct answer is D, Postpartum blues. Postpartum blues, also known as baby blues, are common after childbirth and are characterized by symptoms like tearfulness, insomnia, lack of appetite, and a feeling of letdown. This condition is typically self-limiting and resolves without specific treatment. Postpartum fatigue (choice A) refers to extreme tiredness after childbirth but does not typically include symptoms like tearfulness and insomnia. Postpartum psychosis (choice B) is a severe condition that includes symptoms such as hallucinations and delusions, which are not present in the scenario. The letting-go phase (choice C) does not represent a specific postpartum condition related to the symptoms described.

5. A client in labor is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

• A. Contractions that last for 60 seconds each with a 4-minute rest between contractions
• B. A contraction that lasts 4 minutes followed by a period of relaxation
• C. Contractions that last for 60 seconds each with a 3-minute rest between contractions
• D. Contractions that last 45 seconds each with a 3-minute rest between contractions

Correct answer: C

Rationale: The correct answer is C. When contractions are 4 minutes apart, it means there are 4 minutes from the start of one contraction to the start of the next. If each contraction lasts 60 seconds, there will be a 3-minute rest period between contractions. This allows for adequate uterine relaxation and recovery before the next contraction begins. Choice A is incorrect because it suggests a 4-minute rest between contractions, which is not accurate. Choice B is incorrect as contractions lasting 4 minutes continuously without rest would be concerning. Choice D is incorrect as it suggests 45-second contractions instead of 60-second contractions.

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