Nursing Elites

1. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?

• A. Uterine fundus is firm and midline
• B. Client's perineal pad is saturated in 15 minutes
• C. Client reports breast tenderness when breastfeeding
• D. Client's temperature is 100.4°F

Correct answer: B

Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.

2. A healthcare professional is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement?

• A. 2
• B. 5
• C. 7
• D. 9

Correct answer: A

Rationale: The correct answer is A: '2'. Gastric contents with a pH between 0 and 4 provide a good indication of appropriate tube placement. A pH of 2 is within this range, indicating that the tube is correctly placed in the stomach. Choices B, C, and D are incorrect because a pH of 5, 7, or 9 does not fall within the expected acidic pH range of gastric fluid.

3. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?

• A. Axillary temperature 36.5°C (97.7°F)
• B. Nasal flaring
• C. Heart rate 158/min
• D. One void since birth

Correct answer: B

Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.

4. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?

• A. Place weight on the underarms.
• B. Keep the elbows extended when walking.
• C. Support your weight on your hands.
• D. Hold the crutches 10 cm in front of you when standing.

Correct answer: C

Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.

5. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?

• A. Administer oxygen
• B. Stimulate the newborn
• C. Initiate positive pressure ventilation
• D. Continue routine monitoring

Correct answer: D

Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.

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