Nursing Elites

1. What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?

• A. It must be a comfort to know you have another child.
• B. I'm sad for you.
• C. There is usually something wrong with the baby.
• D. You will always have an angel in heaven.

Correct answer: B

Rationale: Option B, 'I'm sad for you,' is the most appropriate response for the nurse to make to the client who has experienced a perinatal death. This statement conveys empathy and compassion, acknowledging the client's grief and validating their emotions. It opens the door for the client to express their feelings and facilitates further communication and support from the nurse. Choices A, C, and D are not appropriate in this context. Choice A may come across as dismissive of the client's grief by redirecting the focus to another child. Choice C suggests blame or fault, which is not helpful or accurate in most cases of perinatal death. Choice D, while well-intentioned, may not be comforting to all clients and could impose a specific belief system on the client's experience.

2. While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?

• A. Conjunctivitis
• B. Bronze skin discoloration
• C. Sunken fontanels
• D. Maculopapular skin rash

Correct answer: C

Rationale: Sunken fontanels should be prioritized for reporting as they indicate dehydration, which is a critical concern in infants undergoing phototherapy. Dehydration can lead to serious complications, making it essential for the nurse to promptly inform the charge nurse for appropriate intervention and management. Conjunctivitis, bronze skin discoloration, and maculopapular skin rash are important findings to note, but in this scenario, sunken fontanels take precedence due to the potential severity of dehydration in infants.

3. During a weekly prenatal visit, a nurse is assessing a client at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 136/88 mm Hg
• B. Report of insomnia
• C. Weight gain of 2.2 kg (4.8 lb)
• D. Report of Braxton-Hicks contractions

Correct answer: C

Rationale: A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range for a client at 38 weeks of gestation and could indicate complications such as preeclampsia or gestational hypertension. Rapid weight gain at this stage requires immediate attention and should be reported to the provider for further evaluation and management. Choices A, B, and D are not the priority findings to report to the provider at this stage of gestation. Blood pressure of 136/88 mm Hg is within normal limits in pregnancy, insomnia is common in the third trimester, and Braxton-Hicks contractions are expected in the third trimester as the body prepares for labor.

4. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?

• A. 1+ pitting sacral edema
• B. 3+ protein in the urine
• C. Blood pressure 148/98 mm Hg
• D. Deep tendon reflexes of +1

Correct answer: D

Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.

5. When reinforcing teaching with new parents on bathing a newborn, a nurse observes a bluish-brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation?

• A. This is more commonly seen in newborns who have dark skin.
• B. This is a finding indicating hyperbilirubinemia.
• C. This is a forceps mark from an operative delivery.
• D. This is related to prolonged birth or trauma during delivery.

Correct answer: A

Rationale: A bluish-brown marking across the lower back is more commonly seen in newborns with dark skin. These markings are known as Mongolian spots and are benign. They are not related to hyperbilirubinemia, forceps marks, or trauma during delivery. Choice B is incorrect because hyperbilirubinemia presents as jaundice, not as a bluish-brown marking. Choice C is incorrect because forceps marks would have a different appearance and location. Choice D is incorrect as Mongolian spots are not related to prolonged birth or trauma during delivery.

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