Nursing Elites

1. A 30-year-old woman is 22 weeks pregnant with her first child. She tells you that her rings are not fitting as loosely as they usually do and that her ankles are swollen. Her blood pressure is 150/86 mm Hg. She is MOST likely experiencing:

• A. a condition unrelated to pregnancy.
• B. gestational diabetes.
• C. a hypertensive emergency.
• D. preeclampsia.

Correct answer: D

Rationale: The symptoms of swollen ankles, tight rings, and elevated blood pressure in a pregnant woman at 22 weeks gestation are concerning for preeclampsia. Preeclampsia is characterized by high blood pressure and signs of organ damage, commonly seen with symptoms such as swelling (edema) and protein in the urine. It is crucial to monitor and manage preeclampsia promptly as it can lead to severe complications for both the mother and the baby.

2. Seizures in children MOST often result from:

• A. a life-threatening infection.
• B. an inflammatory process in the brain.
• C. an abrupt rise in body temperature.
• D. a temperature greater than 102°F.

Correct answer: C

Rationale: Seizures in children most often result from febrile seizures, which are triggered by an abrupt rise in body temperature. Febrile seizures are common in young children, especially between the ages of 6 months to 5 years, and are usually associated with viral infections that cause a sudden spike in body temperature. Choices A, B, and D are incorrect because while infections, inflammatory processes, and high temperatures can sometimes lead to seizures, the most common cause of seizures in children is an abrupt increase in body temperature, known as febrile seizures.

3. When evaluating a client's fluid intake and output record, how should fluid intake and urine output relate?

• A. Fluid intake should double the urine output
• B. Fluid intake should be approximately equal to the urine output
• C. Fluid intake should be half the urine output
• D. Fluid intake should be inversely proportional to the urine output

Correct answer: B

Rationale: In assessing a client's fluid intake and output record, it is essential for fluid intake to be approximately equal to the urine output. This balance indicates proper hydration and renal function. Deviations from this balance could signify potential issues that need further investigation and management.

4. You are assessing a 26-year-old woman who is 38 weeks pregnant and is in labor. She tells you that she was pregnant once before but had a miscarriage at 19 weeks. You should document her obstetric history as:

• A. gravida 2, para 1.
• B. gravida 2, para 0.
• C. gravida 1, para 1.
• D. gravida 0, para 2.

Correct answer: B

Rationale: In obstetrics, gravida indicates the number of pregnancies, including the current one. Para indicates the number of pregnancies carried to viability (20 weeks or more). Since the patient has been pregnant twice but only carried one pregnancy past 20 weeks, her obstetric history should be documented as gravida 2, para 0. The miscarriage at 19 weeks does not contribute to the para count. Choice A (gravida 2, para 1) would indicate that she has had two pregnancies with one resulting in a live birth, which is incorrect. Choice C (gravida 1, para 1) would indicate that she has had one pregnancy with one live birth, which does not reflect her obstetric history. Choice D (gravida 0, para 2) would indicate that she has never been pregnant past 20 weeks, which is also inaccurate.

5. What should you do immediately upon delivery of a newborn's head?

• A. Suction the nose.
• B. Dry the face.
• C. Cover the eyes.
• D. Suction the mouth.

Correct answer: D

Rationale: Upon delivery of a newborn's head, the priority is to clear the airway to ensure proper breathing. Suctioning the mouth takes precedence over suctioning the nose or other actions to prevent potential airway obstruction. Choice D is the correct answer as it addresses the immediate need to maintain a clear airway for the newborn. Choices A, B, and C are not the correct actions to take at this moment as they do not directly address the crucial need to establish a clear airway for the newborn.

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