Nursing Elites

1. A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital. The emergency room nurse reported the mother has active herpes (HSV II) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery?

• A. Document the newborn's temperature on the flow sheet.
• B. Place the newborn in the isolation area of the nursery.
• C. Obtain a blood specimen for a serum glucose level.
• D. Administer the vitamin K injection.

Correct answer: B

Rationale: Newborns exposed to active herpes lesions are at high risk for neonatal herpes, which can be severe. Placing the newborn in isolation is crucial as it helps prevent the spread of the virus and allows for close monitoring. Documenting the newborn's temperature, obtaining a blood specimen for a serum glucose level, and administering the vitamin K injection are important interventions but are not the priority when dealing with a potential infectious risk like neonatal herpes.

2. A client who has mild preeclampsia and will be caring for herself at home during the last 2 months of pregnancy is receiving teaching from a healthcare provider. Which statement by the client indicates an understanding of the teaching?

• A. “I will count baby’s kicks every other day.”
• B. “I will alternate the arm used to check my blood pressure.”
• C. “I will consume 50 grams of protein daily.”
• D. ---

Correct answer: B

Rationale: The correct answer is B. Alternating arms for blood pressure checks ensures more accurate readings and helps monitor preeclampsia. Option A, counting baby's kicks every other day, is not specific to managing preeclampsia. Option C, consuming 50 grams of protein daily, is important for a healthy diet during pregnancy but does not directly relate to preeclampsia management.

3. 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.

4. When reviewing the electronic medical record of a postpartum client, which of the following factors places the client at risk for infection?

• A. Meconium-stained amniotic fluid
• B. Placenta previa
• C. Midline episiotomy
• D. Gestational hypertension

Correct answer: C

Rationale: The correct answer is C: Midline episiotomy. An episiotomy is a surgical incision made during childbirth to enlarge the vaginal opening. This procedure increases the risk of infection in the postpartum period due to the incision site being a potential entry point for pathogens. Meconium-stained amniotic fluid (choice A) is a risk factor for fetal distress but does not directly increase the mother's risk of infection. Placenta previa (choice B) is a condition where the placenta partially or completely covers the cervix, leading to potential bleeding issues but not necessarily an increased risk of infection. Gestational hypertension (choice D) is a hypertensive disorder that affects some pregnant women but is not directly associated with an increased risk of infection in the postpartum period.

5. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?

• A. Assessing FHR and maternal vital signs.
• B. Performing a venipuncture for hemoglobin and hematocrit levels.
• C. Placing clean disposable pads to collect any drainage.
• D. Monitoring uterine contractions.

Correct answer: A

Rationale: The highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to assess the fetal heart rate (FHR) and maternal vital signs. This assessment is crucial in determining the extent of blood loss and its impact on both the mother and the fetus. Ensuring the well-being of both the mother and the fetus is the top priority in this situation. While obtaining hemoglobin and hematocrit levels is important, it can be done after the initial assessment. Placing clean disposable pads is necessary for managing any drainage but does not take precedence over assessing vital signs. Monitoring uterine contractions is important but is not the highest priority when compared to assessing the FHR and maternal vital signs.

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