Nursing Elites

1. A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?

• A. Contraction durations of 95 to 100 seconds
• B. Contraction frequency of 2 to 3 minutes apart
• C. Absent early deceleration of fetal heart rate
• D. Fetal heart rate is 140/min

Correct answer: A

Rationale: The correct answer is A. Contraction durations of 95 to 100 seconds are prolonged, indicating uterine hyperstimulation, which can lead to fetal distress and requires immediate intervention. Reporting this finding to the provider is crucial to ensure timely management and prevent adverse outcomes. Choice B, contraction frequency of 2 to 3 minutes apart, is within the normal range and does not raise immediate concerns. Choice C, absent early deceleration of fetal heart rate, is a reassuring finding suggesting fetal well-being. Choice D, a fetal heart rate of 140/min, is also normal for a fetus and does not typically require immediate reporting unless it deviates significantly from the baseline or is accompanied by other concerning signs.

2. A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

• A. Obtain a blood sample for a serum glucose level
• B. Feed the newborn immediately
• C. Administer 50 mL of dextrose solution IV
• D. Reassess the blood glucose level prior to the next feeding

Correct answer: D

Rationale: A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn. Reassessing the blood glucose level prior to the next feeding ensures ongoing monitoring without unnecessary intervention. Obtaining a blood sample for a serum glucose level (Choice A) is not necessary as the initial reading is normal. Feeding the newborn immediately (Choice B) may not be indicated and could lead to unnecessary interventions. Administering dextrose solution IV (Choice C) is not warranted as the glucose level is within the normal range and does not require immediate correction.

3. If an individual receives a recessive gene for eye color from both parents, the:

• A. gender of the child will not determine the expression of that trait.
• B. recessive trait will be expressed in the child.
• C. recessive trait will be expressed in all the offspring.
• D. recessive trait will be suppressed, and the dominant trait will not be expressed.

Correct answer: B

Rationale: When an individual inherits a recessive gene for eye color from both parents, the recessive trait will be expressed in the child. This is because having two copies of the recessive gene overrides the presence of any dominant gene. Choice A is incorrect because the expression of the trait is determined by the genetic makeup, not the gender of the child. Choice C is incorrect as the expression of the recessive trait is certain when both parents pass on the recessive gene, but it does not mean that all offspring will express the trait. Choice D is incorrect because if both parents provide a recessive gene, the dominant trait will not be expressed in the child, but it does not mean it will be suppressed; rather, the recessive trait will be expressed.

4. What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

• A. Assessing the strength of uterine contractions
• B. Re-evaluating the need for medication
• C. Reminding her to push 3 times with each contraction
• D. Assisting her to maintain control

Correct answer: D

Rationale: During the transitional phase of labor, which is the most intense phase, the primary focus of nursing care for a client who anticipates an unmedicated delivery should be assisting her to maintain control. This is essential to help her manage the intense pain and anxiety associated with this phase without the use of medication. Assessing the strength of uterine contractions (Choice A) is important but not the primary focus during the transitional phase. Re-evaluating the need for medication (Choice B) is not applicable as the client anticipates an unmedicated delivery. Reminding her to push 3 times with each contraction (Choice C) is more related to the pushing stage of labor and not the transitional phase.

5. A prenatal educator is teaching a class about false labor. Which of the following information should the educator include?

• A. Contractions will become more intense with walking
• B. There will be dilation and effacement of the cervix
• C. There will be bloody show
• D. Contractions will become temporarily regular

Correct answer: D

Rationale: The correct answer is D. False labor contractions, also known as Braxton Hicks contractions, are typically irregular and do not lead to cervical dilation or effacement. They are often described as sporadic and temporary, becoming temporarily regular. Choices A, B, and C are incorrect because false labor contractions do not intensify with activity, do not cause cervical changes like dilation and effacement, and are not associated with the presence of a bloody show.

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