Nursing Elites

1. 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.

2. A client who is at 39 weeks of gestation and is in active labor has fetal heart tones located above the umbilicus at midline. The fetus is likely in which of the following positions?

• A. Cephalic
• B. Transverse
• C. Posterior
• D. Frank breech

Correct answer: D

Rationale: Fetal heart tones above the umbilicus at midline are indicative of a breech presentation, specifically a frank breech position. In a frank breech position, the baby's buttocks are presenting first, which aligns with the fetal heart tones being above the umbilicus. This position indicates that the baby is not in the normal head-down position for birth, which can impact the delivery process and may require specific interventions. Cephalic presentation (Choice A) is the normal head-down position for birth, transverse lie (Choice B) is when the baby is positioned horizontally in the uterus, and posterior position (Choice C) refers to the baby's back being positioned towards the mother's back.

3. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

• A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
• B. A fourth-degree episiotomy extends into the rectal area and is not recommended
• C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
• D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

4. A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

• A. Respirations less than 12/min
• B. Urinary output less than 25 mL/hr
• C. Decreased level of consciousness
• D. All of the above

Correct answer: D

Rationale: Signs of magnesium sulfate toxicity include respirations less than 12/min, urinary output less than 25 mL/hr, and decreased level of consciousness. These signs indicate potential overdose of magnesium sulfate and require immediate attention to prevent further complications. Reporting these signs promptly is crucial to ensure the client's safety and well-being. Choice D, 'All of the above,' is the correct answer as all the listed findings are indicative of magnesium sulfate toxicity. Choices A, B, and C individually represent different signs of toxicity, making them incorrect on their own. Therefore, the nurse should be vigilant in identifying and reporting all these signs to prevent adverse outcomes.

5. A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?

• A. Vastus lateralis
• B. Ventrogluteal
• C. Dorsogluteal
• D. Deltoid

Correct answer: A

Rationale: Vitamin K is typically administered in the vastus lateralis muscle of a newborn to prevent bleeding disorders. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and accessibility, allowing for easy and safe administration. The ventrogluteal and dorsogluteal sites are more commonly used in adults due to better muscle mass and less risk of injury to nearby structures. The deltoid muscle is typically used for older children and adults for IM injections, as it is a well-developed muscle suitable for injections in these populations.

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