Nursing Elites

1. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

• A. Allow liberal family visitation
• B. Keep an airway at the bedside
• C. Assess temperature every hour
• D. Monitor blood pressure, pulse, and respiration every 4 hours

Correct answer: B

Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.

2. The _________ is the hollow organ within females in which the embryo and fetus develop.

• A. placenta
• B. ovum
• C. uterus
• D. amniotic sac

Correct answer: C

Rationale: The correct answer is C: uterus. The uterus is the organ where the embryo implants and the fetus develops during pregnancy. The placenta (choice A) is an organ that develops during pregnancy and provides nutrients and oxygen to the fetus, but it is not the organ where the embryo and fetus physically develop. The ovum (choice B) is the female reproductive cell or egg that is fertilized by the sperm to form an embryo, but it is not the organ where the embryo and fetus develop. The amniotic sac (choice D) is a membrane filled with amniotic fluid that surrounds and protects the fetus, but it is not the organ where the embryo and fetus physically develop.

3. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?

• A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
• B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
• C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
• D. Record the findings on the chart. They are within normal limits.

Correct answer: D

Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.

4. A client at 20 weeks of gestation has trichomoniasis. Which of the following findings should the nurse expect?

• A. Thick, White Vaginal Discharge
• B. Urinary Frequency
• C. Vulvar Lesions
• D. Malodorous Discharge

Correct answer: D

Rationale: Malodorous discharge is a common symptom of trichomoniasis caused by the Trichomonas vaginalis parasite. It is typically described as frothy, greenish-yellow, and malodorous. Choices A, B, and C are incorrect findings associated with other conditions. Thick, white vaginal discharge is more characteristic of a yeast infection; urinary frequency may be seen in urinary tract infections; and vulvar lesions are commonly seen in herpes simplex virus infections.

5. A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes. The nurse observes several shallow small vesicles on her pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition?

• A. Genital Warts
• B. Syphilis
• C. Herpes Simplex Virus
• D. German Measles

Correct answer: C

Rationale: The correct answer is C: Herpes Simplex Virus (HSV). HSV can present with small vesicles on the genital area, and it is a concern during labor due to the risk of transmission to the newborn. Genital warts (Choice A) are caused by the human papillomavirus (HPV) and typically present as flesh-colored growths, not vesicles. Syphilis (Choice B) manifests as painless sores and can have systemic effects but does not typically present with vesicles. German measles (Choice D), also known as Rubella, is a viral illness characterized by a red rash, fever, and lymphadenopathy, not vesicles.

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