Nursing Elites

1. A client who is pregnant is scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply)

• A. Decreased fetal movement
• B. Intrauterine growth restriction (IUGR)
• C. Postmaturity
• D. All of the Above

Correct answer: D

Rationale: A contraction stress test (CST) is performed to assess how the fetus responds to the stress of contractions. Indications for this test include decreased fetal movement, intrauterine growth restriction (IUGR), and postmaturity. These conditions may warrant the need for a CST to evaluate fetal well-being and determine appropriate management. Therefore, all of the above options are correct indications for a contraction stress test. Options A, B, and C are incorrect because they are all valid reasons for performing a CST in a pregnant client.

2. A client is 1 hour postpartum and the nurse observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

• A. Notify the healthcare provider.
• B. Increase the frequency of fundal massage.
• C. Encourage the client to empty their bladder.
• D. Document the findings and continue to monitor the client.

Correct answer: D

Rationale: In the postpartum period, the presence of lochia rubra and small clots along with a firm, midline fundus at the umbilicus is considered normal. In this situation, the appropriate action is to document the findings and continue to monitor the client. Changes in the amount and character of lochia, deviation of the fundus from the midline, or fundal height above or below the expected level may indicate a need for further intervention. Encouraging bladder emptying is important but not the priority in this scenario. Notify the healthcare provider if there are signs of abnormal postpartum bleeding or fundal abnormalities. Therefore, choice D is the correct answer. Choices A, B, and C are incorrect because at this stage, there are no signs of abnormality that require immediate notification of the healthcare provider, increased frequency of fundal massage, or immediate bladder emptying.

3. During the admission assessment of a newborn, which anatomical landmark should be used for measuring the newborn's chest circumference?

• A. Sternal notch
• B. Nipple line
• C. Xiphoid process
• D. Fifth intercostal space

Correct answer: B

Rationale: When measuring a newborn's chest circumference, the appropriate anatomical landmark to use is the nipple line. This point is consistent and allows for accurate and standardized measurements across all newborn assessments. The sternal notch is not typically used for chest circumference measurements in newborns. The xiphoid process is located at the lower end of the sternum and is not an appropriate landmark for chest circumference measurement. The fifth intercostal space is typically used for locating the point of maximal impulse (PMI) during cardiac assessments, not for measuring chest circumference.

4. A client in active labor is being prepared for epidural analgesia. Which of the following actions should the nurse take?

• A. Have the client sit upright on the bed with legs crossed.
• B. Administer a 500 mL bolus of lactated Ringer's solution prior to induction.
• C. Inform the client that the anesthetic effect will last for approximately 2 hours.
• D. Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction.

Correct answer: D

Rationale: Obtaining a 30-minute electronic fetal monitoring (EFM) strip prior to epidural analgesia is crucial to establish a baseline for fetal heart rate and uterine activity. This baseline helps in monitoring fetal well-being during labor and assessing the effect of analgesia on the baby. It enables the healthcare team to identify any changes in the fetal heart rate pattern and uterine contractions, ensuring the safety of both the mother and the baby. Choices A, B, and C are incorrect because having the client sit upright with legs crossed is not necessary for epidural placement, administering a bolus of lactated Ringer's solution is not typically done before epidural analgesia, and the duration of the anesthetic effect varies and is not accurately 2 hours.

5. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?

• A. Perform a sharp hand clap near the infant.
• B. Hold the newborn vertically allowing one foot to touch the table surface.
• C. Place a finger at the base of the newborn's toes.
• D. Turn the newborn's head quickly to one side.

Correct answer: A

Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.

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