Nursing Elites

1. A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?

• A. Avoid sitting for long periods of time.
• B. Apply a cold pack to the perineal area for the first 24 hours.
• C. Use a sitz bath once per week.
• D. Begin Kegel exercises after the first week.

Correct answer: B

Rationale: The correct statement to include in the teaching is to apply a cold pack to the perineal area for the first 24 hours. This helps reduce swelling and promote comfort, aiding in the healing process after an episiotomy. Option A is incorrect as it does not provide specific guidance on managing postpartum recovery. Option C is incorrect because using a sitz bath once per week may not be frequent enough for proper wound care. Option D is incorrect because beginning Kegel exercises immediately after delivery can put excessive strain on the perineal area, potentially hindering healing.

2. A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?

• A. Contraction frequency of every 3 minutes
• B. Contraction duration of 80 seconds
• C. Late decelerations in the fetal heart rate
• D. Urine output of 50 mL/hr

Correct answer: C

Rationale: Late decelerations in the fetal heart rate require immediate intervention as they can indicate fetal distress due to uteroplacental insufficiency. This finding suggests a compromised blood flow to the fetus, which can lead to serious complications if not addressed promptly. Contraction frequency and duration are important to monitor but do not necessitate immediate intervention unless they are causing fetal distress. Urine output of 50 mL/hr is within the normal range for a client in labor and does not require immediate intervention.

3. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?

• A. Feed the newborn on demand
• B. Apply warm compresses to the breast before feeding
• C. Massage the breast after feedings
• D. Ensure the newborn empties one breast before switching to the other

Correct answer: D

Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.

4. A client in the first stage of labor is experiencing lower back pain and asks the nurse what can be done to relieve the pain. Which of the following interventions should the nurse suggest?

• A. Perform effleurage on the client's abdomen
• B. Apply counterpressure to the client's sacrum
• C. Provide a back massage with lavender oil
• D. Administer opioid analgesics

Correct answer: B

Rationale: Applying counterpressure to the sacrum can help alleviate lower back pain during labor by reducing pressure on the nerves. Effleurage on the abdomen, back massage with lavender oil, and administering opioid analgesics are not specifically targeted at relieving lower back pain, making them less effective interventions in this scenario.

5. A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?

• A. Administer 1 oz of glucose water every 2 hours
• B. Feed the newborn 60 mL of formula every 4 hours
• C. Offer sterile water between feedings
• D. Initiate phototherapy

Correct answer: D

Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.

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