Nursing Elites

1. A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should eat foods high in protein before bedtime.
• B. You should avoid consuming liquids with your meals.
• C. You should eat three large meals per day.
• D. You should consume caffeine to help with nausea.

Correct answer: B

Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.

2. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?

• A. Continue to monitor the fetal heart rate
• B. Reposition the client
• C. Administer oxygen via face mask
• D. Increase the rate of the IV fluids

Correct answer: A

Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.

3. A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 160/min
• B. Axillary temperature 36.8°C (98.2°F)
• C. Yellow-tinged skin
• D. Respiratory rate 42/min

Correct answer: C

Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.

4. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?

• A. Caput succedaneum
• B. Jaundice
• C. Acrocyanosis
• D. Overlapping cranial sutures

Correct answer: B

Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.

5. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?

• A. Feed the newborn on demand
• B. Apply warm compresses to the breast before feeding
• C. Massage the breast after feedings
• D. Ensure the newborn empties one breast before switching to the other

Correct answer: D

Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.

Similar Questions