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 full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

• A. Heart rate 168/min
• B. Respiratory rate 18/min
• C. Tremors
• D. Fine crackles

Correct answer: B

Rationale: A newborn's respiratory rate can vary between 20 to 100 breaths per minute during the initial phase after birth. A respiratory rate as low as 18 breaths per minute at this early stage requires immediate nursing intervention. This finding necessitates further assessment to ensure adequate oxygenation and respiratory function. The other options, heart rate of 168/min, tremors, and fine crackles, are within normal limits for a full-term newborn and do not require immediate intervention.

3. A client is being educated by a healthcare provider about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

• A. I should gain more than 15 to 20 pounds during my pregnancy.
• B. I will likely need to use alternative positions for sexual intercourse.
• C. I'm glad I had a breast reduction years ago so they will not enlarge with my pregnancy.
• D. I'm glad I have a light complexion and will not get any stretch marks.

Correct answer: B

Rationale: During pregnancy, weight gain is expected. The client's understanding is demonstrated by acknowledging the need for alternative sexual positions due to the physiological changes, such as weight gain and a growing abdomen. This statement reflects comprehension of the teaching provided by the healthcare provider.

4. 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.

5. 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.

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