Nursing Elites

1. While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

• A. Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
• B. Keep the newborn in a shirt while under the phototherapy light.
• C. Apply a light moisturizing lotion to the newborn's skin.
• D. Turn and reposition the newborn every 4 hours while undergoing phototherapy.

Correct answer: A

Rationale: It is crucial to cover the newborn's eyes with an opaque eye mask to prevent damage to the retinas and corneas from the phototherapy light. The eyes are particularly sensitive to the light used in phototherapy, and shielding them helps protect the newborn's delicate eyes from potential harm. Choice B is incorrect because the newborn should be undressed to maximize skin exposure to the phototherapy light. Choice C is incorrect because lotions or oils can interfere with the effectiveness of phototherapy. Choice D is incorrect because the newborn should be kept as still as possible to maximize exposure to the light.

2. A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?

• A. Decreased vaginal discharge
• B. A surge of energy
• C. Urinary retention
• D. Weight gain of 0.5 to 1.5 kg

Correct answer: B

Rationale: A surge of energy is a common sign that precedes labor. This burst of energy, often referred to as the 'nesting instinct,' is believed to occur as the body prepares for labor, prompting the individual to undertake tasks to prepare for the arrival of the baby. Decreased vaginal discharge is not a typical sign preceding labor. Urinary retention is not a sign that precedes labor and may indicate another issue. Weight gain of 0.5 to 1.5 kg is not a specific sign of impending labor.

3. A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)

• A. Provide ice chips.
• B. Insert an indwelling urinary catheter.
• C. Administer opioid analgesic medication.
• D. Provide ice chips.

Correct answer: C

Rationale: During labor, effective pain management is crucial. The nurse should assist the client with patterned breathing techniques to help manage pain and administer opioid analgesic medication as ordered. Providing ice chips is a comfort measure but does not directly address pain relief. Inserting a urinary catheter is not typically indicated at this stage of labor unless there are specific medical indications, such as the need to closely monitor urine output. Therefore, the correct action for the nurse to prepare to take in this scenario is to administer opioid analgesic medication.

4. A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

• A. Joint pain
• B. Malaise
• C. Rash
• D. Tender lymph nodes

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

5. A client is postpartum and has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect?

• A. Decreased platelet count
• B. Increased erythrocyte sedimentation rate (ESR)
• C. Decreased megakaryocytes
• D. Increased WBC

Correct answer: A

Rationale: Idiopathic thrombocytopenic purpura (ITP) is characterized by an autoimmune response that leads to a decreased platelet count. This condition increases the risk of bleeding due to the low platelet levels. Monitoring the platelet count is crucial in managing ITP, as it helps determine the risk of bleeding and guides treatment decisions. Therefore, the correct finding to expect in a client with ITP is a decreased platelet count. Choice B, an increased erythrocyte sedimentation rate (ESR), is not typically associated with ITP. Choice C, decreased megakaryocytes, may be seen in conditions like aplastic anemia but are not a typical finding in ITP. Choice D, an increased white blood cell count (WBC), is not a characteristic feature of ITP.

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