Nursing Elites

1. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take?

• A. Assess bowel sounds.
• B. Continue to monitor.
• C. Assist with intubation.
• D. Rub the infant's back.

Correct answer: B

Rationale: Cyanosis of the hands and feet, known as acrocyanosis, is common in newborns shortly after birth and usually resolves on its own. It is not indicative of a need for immediate intervention. Therefore, the appropriate action is to continue monitoring the newborn's condition. Assessing bowel sounds (Choice A) is not relevant to the presenting issue of cyanosis and respiratory rate. Assisting with intubation (Choice C) is an invasive procedure that is not warranted based on the information provided. Rubbing the infant's back (Choice D) is not necessary for acrocyanosis and could potentially disturb the newborn.

2. A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment warrants immediate intervention by the nurse?

• A. Fetal Heart rate 60 beats per minute
• B. Ruptured amniotic membrane
• C. Onset of uterine contractions
• D. Leaking amniotic fluid

Correct answer: A

Rationale: A fetal heart rate of 60 beats per minute is significantly below the normal range (110-160 bpm) and indicates fetal distress, requiring immediate intervention. This low heart rate can be a sign of fetal compromise or distress, necessitating urgent evaluation and intervention to ensure the well-being of the fetus. Choices B, C, and D do not indicate immediate fetal distress requiring urgent intervention. Ruptured amniotic membrane, onset of uterine contractions, and leaking amniotic fluid are important assessments but do not present an immediate threat to the fetus's life like a severely low fetal heart rate.

3. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?

• A. Administer indomethacin
• B. Insert a second 22-gauge IV catheter.
• C. Insert an indwelling urinary catheter.
• D. Administer oxygen at 4L/min via nasal cannula.

Correct answer: D

Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.

4. When discussing risk factors for gestational diabetes mellitus (GDM) with a group of pregnant clients, which ethnicity should the nurse identify as having the lowest incidence of GDM?

• A. Asian
• B. Non-Hispanic White American
• C. Hispanic
• D. African American

Correct answer: B

Rationale: Non-Hispanic White Americans have the lowest incidence of gestational diabetes mellitus (GDM) compared to other ethnicities. This is because GDM is more prevalent among certain ethnic groups, such as Asian, Hispanic, and African American populations. Asian individuals have an increased risk of developing GDM due to genetic factors, while Hispanic and African American populations have higher incidences of GDM due to lifestyle and genetic predispositions. Therefore, the correct answer is B, as Non-Hispanic White Americans generally have a lower risk of developing GDM.

5. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?

• A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
• B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
• C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
• D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

Correct answer: B

Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.

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