Nursing Elites

1. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

2. A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following factors is strongly associated with this postpartum complication?

• A. Cesarean birth
• B. Vaginal birth
• C. Anemia
• D. Multiparity

Correct answer: A

Rationale: The correct answer is A: Cesarean birth. Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors for DVT include smoking, obesity, and a history of thromboembolism. Vaginal birth, anemia, and multiparity are not strongly associated with an increased risk of deep-vein thrombosis postpartum. It is important to educate clients undergoing cesarean birth about the increased risk of DVT and measures to prevent it, such as early ambulation and the use of compression stockings.

3. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?

• A. Respiratory rate
• B. Blood pressure
• C. Pain level
• D. Heart rate

Correct answer: A

Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.

4. A client has been prescribed raloxiphene. As the nurse, you know that raloxiphene is used to treat:

• A. Migraines
• B. Hypertension
• C. Osteoporosis
• D. Heart disease

Correct answer: C

Rationale: Raloxiphene (Evista) is a selective estrogen receptor modulator (SERM) used primarily to prevent and treat osteoporosis in postmenopausal women. It helps to maintain bone density and reduce the risk of fractures by mimicking the effects of estrogen on bone tissue. It is not indicated for the treatment of migraines, hypertension, or heart disease. Therefore, the correct answer is osteoporosis (Choice C). Choices A, B, and D are incorrect as raloxiphene is not used to treat migraines, hypertension, or heart disease.

5. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

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