Nursing Elites

1. A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

• A. Apply cold compresses to the affected extremity
• B. Massage the affected extremity
• C. Allow the client to ambulate
• D. Measure leg circumferences

Correct answer: D

Rationale: Measuring leg circumferences is crucial in monitoring for changes that may indicate worsening of thrombophlebitis, such as increased swelling or redness. This assessment helps in early detection of complications and timely intervention, reducing the risk of further health problems for the client. Applying cold compresses may worsen the condition by causing vasoconstriction. Massaging the affected extremity can dislodge a clot and lead to embolism. Allowing the client to ambulate may increase the risk of clot migration.

2. When caring for a client in labor, which of the following infections can be treated during labor or immediately following birth? (Select all that apply)

• A. Gonorrhea
• B. Chlamydia
• C. HIV
• D. All of the Above

Correct answer: D

Rationale: Infections such as gonorrhea, chlamydia, and HIV can be treated during labor or immediately following birth to prevent transmission to the newborn. It is crucial to identify and treat these infections promptly to reduce the risk of vertical transmission to the infant. Therefore, all the given options are correct as they can be treated during labor or immediately following birth to prevent transmission to the newborn. Other choices are incorrect because only gonorrhea, chlamydia, and HIV can be effectively treated during labor or immediately after birth to prevent vertical transmission.

3. A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?

• A. Persistent abdominal striae
• B. Temperature 37.8° C (100.2° F)
• C. Unilateral breast pain
• D. Brownish-red discharge on day 5

Correct answer: C

Rationale: Unilateral breast pain can be a sign of mastitis, an infection of the breast tissue, which requires prompt evaluation and treatment. The nurse should instruct the client to report this clinical manifestation to the provider to prevent complications and promote recovery.

4. A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?

• A. Peanut butter
• B. Potatoes
• C. Apple juice
• D. Broccoli

Correct answer: A

Rationale: Individuals with phenylketonuria (PKU) have difficulty breaking down phenylalanine, an amino acid found in protein-rich foods like peanut butter. Therefore, clients with PKU should avoid foods high in phenylalanine, such as peanut butter, to prevent adverse effects on their health. Choices B, C, and D are not typically high in phenylalanine and do not pose the same risk to individuals with PKU as peanut butter.

5. While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

• A. Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
• B. Keep the newborn in a shirt while under the phototherapy light.
• C. Apply a light moisturizing lotion to the newborn's skin.
• D. Turn and reposition the newborn every 4 hours while undergoing phototherapy.

Correct answer: A

Rationale: It is crucial to cover the newborn's eyes with an opaque eye mask to prevent damage to the retinas and corneas from the phototherapy light. The eyes are particularly sensitive to the light used in phototherapy, and shielding them helps protect the newborn's delicate eyes from potential harm. Choice B is incorrect because the newborn should be undressed to maximize skin exposure to the phototherapy light. Choice C is incorrect because lotions or oils can interfere with the effectiveness of phototherapy. Choice D is incorrect because the newborn should be kept as still as possible to maximize exposure to the light.

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