Nursing Elites

1. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?

• A. 1+ pitting sacral edema
• B. 3+ protein in the urine
• C. Blood pressure 148/98 mm Hg
• D. Deep tendon reflexes of +1

Correct answer: D

Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.

2. A caregiver is learning about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?

• A. I will dress my baby in flame-retardant clothing.
• B. I will ensure a bib on my baby at night to keep her clothing dry.
• C. I will warm my baby's formula using the lowest setting in the microwave.
• D. I will cover the crib mattress with plastic to prevent staining.

Correct answer: A

Rationale: The correct answer is A. Dressing a baby in flame-retardant clothing is crucial to prevent injuries, especially in case of accidental exposure to fire sources. This safety measure can provide an added layer of protection for the newborn. The other options do not directly address newborn safety concerns or best practices. Option B focuses on keeping clothing dry, which is not a primary safety concern. Option C poses a risk of overheating the formula, which can be dangerous for the baby. Option D, covering the crib mattress with plastic, may pose a suffocation hazard to the baby.

3. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?

• A. Perform a sharp hand clap near the infant.
• B. Hold the newborn vertically allowing one foot to touch the table surface.
• C. Place a finger at the base of the newborn's toes.
• D. Turn the newborn's head quickly to one side.

Correct answer: A

Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.

4. A client who received carboprost for postpartum hemorrhage is being assessed by a nurse. Which of the following findings is an adverse effect of this medication?

• A. Hypertension
• B. Hypothermia
• C. Constipation
• D. Muscle weakness

Correct answer: A

Rationale: The correct answer is A: Hypertension. Carboprost is a vasoconstrictor medication used to control postpartum hemorrhage by contracting the uterus. One of the adverse effects of carboprost is hypertension due to its vasoconstrictive properties. Hypertension can occur as a result of increased peripheral vascular resistance. Choices B, C, and D are incorrect. Hypothermia, constipation, and muscle weakness are not typically associated with the administration of carboprost. It is crucial for the nurse to monitor the client's blood pressure closely while on carboprost to promptly detect and manage hypertension.

5. After an amniotomy, what is the priority nursing action?

• A. Observe color and consistency of fluid
• B. Assess the fetal heart rate pattern
• C. Assess the client's temperature
• D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation

Correct answer: B

Rationale: After an amniotomy, the priority nursing action is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress, as changes in the fetal heart rate could indicate potential complications related to the procedure. Observing the color and consistency of the fluid (Choice A) is important but not the priority over assessing fetal well-being. Assessing the client's temperature (Choice C) and evaluating the client for chills and increased uterine tenderness (Choice D) are not immediate priorities following an amniotomy.

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