Nursing Elites

1. A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What should the nurse do first?

• A. Push the call light for help
• B. Inspect the client's perineum
• C. Notify a healthcare provider
• D. Turn on the infant warmer

Correct answer: B

Rationale: Inspecting the client's perineum immediately is necessary to assess if the baby is being delivered, which would require urgent action. Pushing the call light for help (Choice A) may delay the assessment and immediate action needed. Notifying a healthcare provider (Choice C) might cause further delays, as the situation requires urgent attention. Turning on the infant warmer (Choice D) is not the priority; ensuring safe delivery and assessment of the baby's condition come first.

2. A newborn is 24 hours old, and a healthcare provider is caring for them. Which of the following laboratory findings should the healthcare provider report to the provider?

• A. Hgb 20 g/dL
• B. Bilirubin 2 mg/dL
• C. Platelets 200,000/mm3
• D. WBC count 32,000/mm3

Correct answer: D

Rationale: The correct answer is D: WBC count 32,000/mm3. A WBC count of 32,000/mm3 is significantly elevated in a newborn and could indicate an infection, which needs immediate attention and intervention. High white blood cell counts in newborns can be concerning as they may suggest an ongoing infection or other underlying issues that require prompt medical evaluation and treatment. Choices A, B, and C are within normal ranges for a newborn and would not typically warrant immediate reporting to the provider. Hgb levels of 20 g/dL (Choice A) are high for newborns, but this is not as concerning as a significantly elevated WBC count. Bilirubin levels of 2 mg/dL (Choice B) are within normal limits for a newborn and do not indicate immediate issues. Platelet count of 200,000/mm3 (Choice C) is also within the normal range for a newborn and would not require immediate reporting.

3. Twenty-year-old Jack is extremely tall and has very thick facial hair. Most of his male secondary sex characteristics are also more pronounced than men of his age. In this scenario, Jack is most likely:

• A. an XYY male.
• B. diagnosed with Klinefelter syndrome.
• C. an XXY male.
• D. diagnosed with Down syndrome.

Correct answer: A

Rationale: The correct answer is A: an XYY male. Individuals with XYY syndrome often exhibit increased height and more pronounced secondary male characteristics, such as thick facial hair. Choice B, Klinefelter syndrome (XXY), typically presents with less prominent male secondary sex characteristics due to the presence of an extra X chromosome. Choice C, XXY male, refers to Klinefelter syndrome, which does not align with the description of Jack having more pronounced male secondary sex characteristics. Choice D, Down syndrome, is caused by a trisomy of chromosome 21 and is not associated with the physical characteristics described in the scenario.

4. A client experiencing preterm labor is being taught about terbutaline by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “The medication could cause me to experience heart palpitations.”
• B. “This medication could cause me to experience blurred vision.”
• C. “This medication could cause me to experience ringing in my ears.”
• D. “This medication could cause me to experience frequent urination.”

Correct answer: A

Rationale: The correct answer is A. Terbutaline is a beta-adrenergic agonist used to stop preterm labor. One of its common side effects is heart palpitations due to its action on beta receptors in the heart. Choices B and C are incorrect because blurred vision and ringing in the ears are not common side effects of terbutaline. Choice D is irrelevant to the side effects of terbutaline.

5. During a prenatal visit, for which of the following clients should the nurse auscultate the fetal heart rate?

• A. A client who has an ultrasound confirming a molar pregnancy
• B. A client who has a crown-rump length corresponding to 7 weeks gestation
• C. A client who has a positive urine pregnancy test 1 week after missed menses
• D. A client who has felt quickening for the first time

Correct answer: D

Rationale: The correct answer is D because feeling quickening typically occurs around 18-20 weeks of gestation, indicating fetal movement. This is an appropriate time to auscultate the fetal heart rate. Choice A is incorrect because a molar pregnancy is not a viable pregnancy, and auscultating the fetal heart rate in this case is not applicable. Choice B is incorrect because a crown-rump length of 7 weeks gestation is too early for fetal heart rate auscultation. Choice C is incorrect because a positive urine pregnancy test alone does not indicate the appropriate timing for fetal heart rate auscultation.

Similar Questions