Nursing Elites

1. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

• A. Maternal/newborn blood group incompatibility
• B. Absence of vitamin K
• C. Physiologic jaundice
• D. Maternal cocaine abuse

Correct answer: A

Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.

2. A client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?

• A. Fetal heart rate 100/min
• B. Weakened uterine contractions
• C. Enhanced production of fetal lung surfactant
• D. Maternal blood glucose 63 mg/dL

Correct answer: B

Rationale: Terbutaline is a tocolytic medication that works by relaxing the uterine muscles, leading to weakened uterine contractions. This effect helps to prevent preterm labor. Therefore, the nurse should expect weakened uterine contractions in a client who has received terbutaline at 28 weeks of gestation. Choices A, C, and D are incorrect. Terbutaline administration would not directly affect the fetal heart rate, enhance fetal lung surfactant production, or cause maternal hypoglycemia.

3. A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?

• A. On days 13 to 17 of her menstrual cycle
• B. Every morning before arising
• C. 1 hour following intercourse
• D. Before going to bed every night

Correct answer: B

Rationale: The basal body temperature should be taken every morning before arising as it provides the most accurate reading. This time ensures consistency and eliminates variations that may occur throughout the day due to activities or environmental factors. Choice A is incorrect because ovulation can vary among individuals, and checking temperature on specific days may not align with the actual ovulation day. Choice C is incorrect as there is no direct correlation between intercourse and basal body temperature. Choice D is incorrect because taking the temperature before going to bed does not provide a consistent baseline reading.

4. A client in active labor is irritable, reports the urge to have a bowel movement, vomits, and states, 'I've had enough. I can't do this anymore.' Which of the following stages of labor is the client experiencing?

• A. Second stage
• B. Fourth stage
• C. Transition phase
• D. Latent phase

Correct answer: C

Rationale: The client in active labor displaying irritability, the urge to have a bowel movement, nausea, vomiting, and expressing frustration indicates that they are in the transition phase of labor. This phase typically occurs just before entering the second stage of labor, marked by intense contractions and cervical dilation from 8 to 10 centimeters. During this phase, the client may feel overwhelmed, exhausted, and may express a sense of losing control. It is a crucial phase indicating that the client is close to delivering the baby. Choice A, the second stage of labor, is characterized by complete cervical dilation and the birth of the baby, not the symptoms described in the scenario. Choice B, the fourth stage, is the period following the delivery of the placenta, not the phase before giving birth. Choice D, the latent phase, is the early phase of labor where contractions are mild and occur at irregular intervals, not the phase described in the scenario.

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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