Nursing Elites

1. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

• A. A client with a urinary output of 300 ml in 8 hours
• B. A client reporting abdominal cramping during breastfeeding
• C. A client receiving magnesium sulfate with absent deep tendon reflexes
• D. A client reporting lochia rubra requiring changing perineal pads every 3 hours

Correct answer: C

Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.

2. A new parent is receiving discharge teaching about car seat safety from a nurse. Which statement by the parent indicates an understanding of the teaching?

• A. “I should position my baby’s car seat at a 45-degree angle in the car.”
• B. “I should place the car seat rear-facing until my baby is 12 months old.”
• C. “I should place the harness snugly in a slot above my baby’s shoulders.”
• D. “I should position the retainer clip at the top of my baby’s abdomen.”

Correct answer: A

Rationale: The correct answer is A. Positioning the car seat at a 45-degree angle is crucial to prevent the baby's head from falling forward, which can obstruct the airway. Choice B is incorrect because the recommendation is to keep the car seat rear-facing until the baby reaches the height or weight limit set by the car seat manufacturer, typically beyond 12 months. Choice C is incorrect as the harness should be snugly placed at or below the baby's shoulders, not above. Choice D is incorrect as the retainer clip should be positioned at armpit level to secure the harness straps properly.

3. Examination reveals that the laboring client's cervix is dilated to 2 centimeters, 70% effaced with the presenting part at -2 station. The client tells the nurse, 'I need my epidural now, this hurts.' The nurse's response to the client is based on which information?

• A. The client will need to be catheterized before the epidural can be administered.
• B. Administering an epidural at this point would slow down the labor process.
• C. The client should be dilated to at least 8 centimeters before receiving an epidural.
• D. The baby needs to be at a zero station before an epidural can be administered.

Correct answer: B

Rationale: Administering an epidural too early in labor, especially at 2 cm dilation, can slow down the progress of labor. It is usually recommended to wait until labor is more established. Choice A is incorrect because catheterization is not a prerequisite for epidural administration. Choice C is incorrect as waiting until 8 cm dilation is not a standard requirement for epidural administration. Choice D is incorrect because the baby's station being at zero is not a strict criterion for epidural administration.

4. A client who is 24 weeks gestation arrives at the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next?

• A. Review the client's previous blood pressures in the chart.
• B. Obtain the client's blood pressure.
• C. Observe and time the client's contractions.
• D. Examine the client for pedal edema.

Correct answer: B

Rationale: Swollen hands and rapid weight gain could be signs of preeclampsia, so the next step is to check the client's blood pressure. Elevated blood pressure is a key indicator in assessing for preeclampsia in pregnancy. Reviewing the client's previous blood pressures may provide additional context but obtaining the current blood pressure is crucial for immediate assessment. Observing and timing contractions are not relevant in this scenario as the client is not presenting with signs of active labor. Examining for pedal edema is important in assessing for fluid retention, but obtaining the blood pressure takes precedence in this case due to the potential seriousness of preeclampsia.

5. A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?

• A. Provide a calm environment
• B. Monitor blood glucose levels every hour
• C. Initiate seizure precautions
• D. Place the infant on their back with legs extended

Correct answer: C

Rationale: Initiating seizure precautions is crucial when caring for an infant with neonatal abstinence syndrome due to the increased risk of seizures. Providing a calm environment (Choice A) is important to reduce stimulation as these infants may be irritable. Monitoring blood glucose levels (Choice B) is not typically a priority in neonatal abstinence syndrome unless specific signs or symptoms suggest the need for this assessment. Placing the infant on their back with legs extended (Choice D) does not directly address the potential complications associated with neonatal abstinence syndrome, such as seizures.

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