Nursing Elites

1. A healthcare professional is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

• A. Hypertonia
• B. Increased feeding
• C. Hyperthermia
• D. Respiratory distress

Correct answer: D

Rationale: The correct answer is D, respiratory distress, as it is a clinical manifestation of hypoglycemia in newborns. Other signs of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. Hypertonia, increased feeding, and hyperthermia are not typically associated with hypoglycemia in newborns. Hypertonia is more indicative of neurological issues, increased feeding is not a common sign of hypoglycemia, and hyperthermia is not a typical symptom of low blood sugar.

2. A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?

• A. Encourage the parents to touch and explore the newborn's features
• B. Limit noise and interruptions in the delivery room
• C. Place the newborn at the client's breast
• D. Position the newborn skin-to-skin on the client's chest

Correct answer: D

Rationale: Positioning the newborn skin-to-skin on the client's chest is the priority action to promote warmth, regulate the newborn's heart rate and breathing, and enhance parent-infant bonding. This method facilitates early bonding, stabilizes the baby's temperature, and encourages breastfeeding initiation. Encouraging parents to touch and explore the newborn's features is important but not the priority at this moment. Limiting noise and interruptions can be beneficial but not as crucial as skin-to-skin contact for bonding. Placing the newborn at the client's breast is essential for breastfeeding but should come after the initial skin-to-skin contact for bonding and temperature regulation.

3. During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?

• A. Vertex
• B. Shoulder
• C. Breech
• D. Mentum

Correct answer: C

Rationale: The correct answer is C: "Breech." The RSA position indicates that the fetus is in a breech presentation. In a breech presentation, the buttocks or feet are positioned to be delivered first, which can impact the mode of delivery and require close monitoring during labor and birth. Choice A (Vertex) refers to the head-first presentation, which is considered the normal and most common presentation for birth. Choice B (Shoulder) does not represent a specific fetal presentation. Choice D (Mentum) refers to the chin presentation, which is also not relevant in this scenario.

4. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include?

• A. Eat crackers or plain toast before getting out of bed
• B. Awaken during the night to eat a snack
• C. Skip breakfast and eat lunch after nausea has subsided
• D. Eat a large evening meal

Correct answer: A

Rationale: During early pregnancy, nausea and vomiting in the morning are common symptoms. Eating crackers or plain toast before getting out of bed can help manage morning nausea by stabilizing blood sugar levels. This simple and easily digestible snack can alleviate symptoms by providing some sustenance to the stomach before fully waking up and moving around. Choices B, C, and D are incorrect. Waking up during the night to eat a snack may disrupt sleep patterns, skipping breakfast can worsen symptoms by allowing the stomach to remain empty for longer periods, and eating a large evening meal may exacerbate morning nausea due to increased stomach contents.

5. A client is to receive oxytocin to augment labor. Which finding contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

• A. Late decelerations
• B. Moderate variability of the FHR
• C. Cessation of uterine dilation
• D. Prolonged active phase of labor

Correct answer: A

Rationale: Late decelerations are indicative of uteroplacental insufficiency, which can be exacerbated by oxytocin administration, potentially compromising fetal well-being. Therefore, detecting late decelerations should prompt immediate reporting to the provider to prevent harm to the fetus. Choices B, C, and D are not contraindications for initiating oxytocin infusion. Moderate variability of the FHR is a reassuring sign of fetal well-being, cessation of uterine dilation may indicate a pause in labor progress but does not contraindicate oxytocin, and prolonged active phase of labor may necessitate oxytocin administration to augment contractions and progress labor.

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