Nursing Elites

1. At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?

• A. Color and consistency of fluid.
• B. Estimated amount of fluid.
• C. Any odor noted at the rupture of membranes.
• D. Time of membrane rupture.

Correct answer: A

Rationale: Assessing the color and consistency of amniotic fluid is crucial as it can indicate the presence of meconium, which suggests potential fetal distress. This information guides the need for further assessments and interventions to ensure the well-being of the mother and fetus. Estimating the amount of fluid is not as critical as determining the color and consistency to identify fetal distress. While noting any odor is important, it is secondary to assessing the fluid itself. Knowing the time of membrane rupture is helpful but not as crucial as evaluating the characteristics of the amniotic fluid.

2. A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

• A. Advise the mother to wait at least another month before starting any solid foods.
• B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
• C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
• D. Encourage the mother to schedule a developmental assessment of the infant.

Correct answer: C

Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding. Choice A is incorrect because waiting another month is not necessary if the infant is 6 months old. Choice B is incorrect as introducing pureed fruits as the first food may not provide the necessary iron that the infant needs at this stage. Choice D is also incorrect as scheduling a developmental assessment is not indicated solely based on the desire to start solid foods; it is more appropriate to reassure the mother about starting iron-fortified cereal.

3. A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

• A. Wear support stockings.
• B. Reduce salt in her diet.
• C. Move about every hour.
• D. Avoid constrictive clothing.

Correct answer: C

Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.

4. A pregnant woman in her first trimester is experiencing watery vaginal discharge. What should the nurse tell her?

• A. Inform her that it is normal.
• B. Advise her to see a doctor immediately.
• C. Suggest using panty liners.
• D. Suggest a change in diet.

Correct answer: A

Rationale: Informing the pregnant woman that watery vaginal discharge is normal during the first trimester is crucial to providing reassurance and reducing anxiety. This discharge, known as leukorrhea, is common during pregnancy due to increased estrogen levels and increased blood flow to the pelvic area. It helps maintain a healthy balance of bacteria in the vagina and protects the birth canal from infection. Advising the woman to see a doctor immediately may cause unnecessary alarm, while suggesting the use of panty liners can help manage the discharge comfortably. Suggesting a change in diet is not relevant to addressing watery vaginal discharge in this scenario.

5. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

• A. Obtain the healthcare provider’s advice as to when the restraints should be removed.
• B. Remove restraints one at a time to provide range of motion exercises.
• C. Record observation of the restraints q2h and ensure that they are in place at all times.
• D. Remove restraints q4h for 30 minutes and place gloves on the child’s hands.

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

Similar Questions