Nursing Elites

1. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

• A. Assess the blood pressure for hypertension.
• B. Gently massage fundus every four hours.
• C. Observe for signs of uterine hemorrhage.
• D. Encourage direct contact with the infant.

Correct answer: C

Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.

2. A healthcare provider is assessing a newborn immediately following a vaginal birth. For which of the following findings should the provider intervene?

• A. Molding
• B. Vernix Caseosa
• C. Acrocyanosis
• D. Sternal retractions

Correct answer: D

Rationale: Sternal retractions in a newborn indicate respiratory distress and require immediate intervention. This finding suggests the newborn is having difficulty breathing and needs prompt attention to ensure adequate oxygenation. Molding, the overlapping of fetal skull bones during birth, is a normal and expected process that does not require intervention. Vernix Caseosa, the protective white substance on the skin, and Acrocyanosis, the bluish discoloration of extremities, are both common and benign findings in newborns that do not necessitate immediate action. Therefore, the healthcare provider should focus on addressing sternal retractions to manage the respiratory distress effectively.

3. Which of the following illnesses causes degeneration of the central nervous system?

• A. Tay-Sachs disease
• B. Cystic fibrosis
• C. Turner syndrome
• D. Klinefelter syndrome

Correct answer: A

Rationale: Tay-Sachs disease is a genetic disorder that causes a progressive degeneration of the central nervous system, particularly in infants. Choice B, Cystic fibrosis, is a genetic disorder that primarily affects the lungs and digestive system, not the central nervous system. Choices C and D, Turner syndrome and Klinefelter syndrome, are chromosomal disorders that do not directly involve degeneration of the central nervous system.

4. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?

• A. Administer indomethacin
• B. Insert a second 22-gauge IV catheter.
• C. Insert an indwelling urinary catheter.
• D. Administer oxygen at 4L/min via nasal cannula.

Correct answer: D

Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.

5. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?

• A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
• B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
• C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
• D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

Correct answer: B

Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.

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