Nursing Elites

1. A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?

• A. History of anxiety
• B. Socioeconomic status
• C. Hormonal changes with a rapid decline in estrogen and progesterone
• D. Support from family members

Correct answer: C

Rationale: Postpartum depression can be triggered by various factors, but one of the strongest predictors is a rapid drop in estrogen and progesterone levels following childbirth. These hormonal changes can affect mood regulation, making some women more vulnerable to depression during the postpartum period. Choices A, B, and D are not direct risk factors associated with postpartum depression. While a history of anxiety may contribute, it is not as directly linked to the hormonal changes that occur postpartum. Socioeconomic status and support from family members may influence the overall well-being of the mother but are not specific risk factors for postpartum depression.

2. A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?

• A. Notify the provider.
• B. Report the incident to the risk manager.
• C. Check the condition of the patient.
• D. Complete an incident report.

Correct answer: C

Rationale: The healthcare provider should first assess the patient to determine if any harm has occurred as a result of the medication error. Checking the patient's condition takes precedence as it allows for immediate intervention if necessary. Notifying the provider (choice A) can come later once the patient's condition is assessed. Reporting to the risk manager (choice B) and completing an incident report (choice D) are important steps but should follow the initial assessment of the patient to ensure timely and appropriate actions are taken.

3. A healthcare provider is assessing a client with congestive heart failure. Which of the following signs should the healthcare provider monitor?

• A. Peripheral edema
• B. Decreased appetite
• C. Fatigue
• D. All of the above

Correct answer: D

Rationale: Correct! In a client with congestive heart failure, peripheral edema, decreased appetite, and fatigue are important signs to monitor as they can indicate worsening heart failure. Peripheral edema is a common sign of fluid retention due to the heart's inability to pump effectively, decreased appetite may indicate worsening heart function, and fatigue can be a result of inadequate cardiac output. Monitoring all these signs is crucial for early intervention and management. Choices A, B, and C are incorrect because monitoring only one symptom may not provide a comprehensive assessment of the client's condition.

4. A client is in the transition phase of labor. Which of the following actions should the nurse take?

• A. Assist the client to void every 3 hours
• B. Monitor contractions every 30 minutes
• C. Place the client in a lithotomy position
• D. Encourage the client to use a pant-blow breathing pattern

Correct answer: D

Rationale: Encouraging the client to use a pant-blow breathing pattern is crucial during the transition phase of labor. This phase is characterized by intense contractions and emotional responses. Pant-blow breathing helps manage pain and anxiety, providing comfort and support to the client. Voiding every 3 hours is not specific to the transition phase and may not address immediate needs. Monitoring contractions every 30 minutes is important but may not be as directly beneficial as focusing on coping mechanisms like breathing techniques. Placing the client in a lithotomy position is generally not recommended during the transition phase as it can impede progress and comfort.

5. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?

• A. Respiratory rate of 60 per minute
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.

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