Nursing Elites

1. A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

• A. Respirations less than 12/min
• B. Urinary output less than 25 mL/hr
• C. Decreased level of consciousness
• D. All of the above

Correct answer: D

Rationale: Signs of magnesium sulfate toxicity include respirations less than 12/min, urinary output less than 25 mL/hr, and decreased level of consciousness. These signs indicate potential overdose of magnesium sulfate and require immediate attention to prevent further complications. Reporting these signs promptly is crucial to ensure the client's safety and well-being. Choice D, 'All of the above,' is the correct answer as all the listed findings are indicative of magnesium sulfate toxicity. Choices A, B, and C individually represent different signs of toxicity, making them incorrect on their own. Therefore, the nurse should be vigilant in identifying and reporting all these signs to prevent adverse outcomes.

2. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

• A. The newborn will have decreased muscle tone.
• B. The newborn will have a continuous high-pitched cry.
• C. The newborn will sleep for 2 to 3 hours after a feeding.
• D. The newborn will have mild tremors when disturbed.

Correct answer: B

Rationale: The correct answer is B. A continuous high-pitched cry is a characteristic sign of neonatal abstinence syndrome, indicating withdrawal from drugs. Choices A, C, and D are incorrect because decreased muscle tone, sleeping for 2 to 3 hours after a feeding, and mild tremors when disturbed are not specific indicators of neonatal abstinence syndrome.

3. A client is being educated by a healthcare provider about the changes she should expect when planning to become pregnant. Identify the correct sequence of maternal changes. A. Amenorrhea B.Lightening C. Goodell's sign D. Quickening

• A. A,B,C,D
• B. D,B,A,C
• C. A,D,B,C
• D. A,C,D,B

Correct answer: D

Rationale: The correct sequence of maternal changes during pregnancy is as follows: Amenorrhea (absence of menstrual periods), Goodell's sign (softening of the cervix), Quickening (first fetal movements felt by the mother), and Lightening (baby descending into the pelvis). These changes occur at different stages of pregnancy and are important indicators of fetal development and maternal adaptation. Choice A is correct as it is the initial change indicating possible pregnancy. Choices B, C, and D follow in the correct order of occurrence during pregnancy. Choices B, C, and D are incorrect as they do not follow the correct sequence of maternal changes.

4. A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?

• A. Confirm the newborn's identification.
• B. Verify the newborn's identification.
• C. Administer vitamin K to the newborn.
• D. Determine obstetrical risk factors.

Correct answer: B

Rationale: When a newborn is transferred to the nursery, the first action the nurse should take is to verify the newborn's identification. This step is crucial for ensuring the correct care is provided to the right newborn, promoting patient safety and preventing errors. Administering vitamin K (Choice C) is important but should not be the first action. Determining obstetrical risk factors (Choice D) is not the priority when the newborn is transferred to the nursery. Confirming (Choice A) and verifying (Choice B) have similar meanings, but 'verify' is a more appropriate term in this context.

5. When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?

• A. Vaginal bleeding
• B. Swelling of the ankles
• C. Heartburn after eating
• D. Lightheadedness when lying on back

Correct answer: A

Rationale: Vaginal bleeding during pregnancy is a concerning sign that could indicate serious complications like miscarriage or placental issues. Prompt reporting to the healthcare provider is crucial for timely evaluation and management to ensure the best outcomes for both the mother and the baby. Swelling of the ankles (choice B), heartburn after eating (choice C), and lightheadedness when lying on the back (choice D) are common discomforts during pregnancy but are not typically associated with serious complications that require immediate attention.

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