Nursing Elites

1. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

• A. Evaluate the firmness of the uterus.
• B. Initiate oxygen therapy via a non-rebreather mask.
• C. Administer oxytocin infusion.
• D. Obtain a type and crossmatch.

Correct answer: A

Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

2. A nurse is teaching clients in a prenatal class about the importance of taking folic acid during pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities?

• A. Neural tube defect
• B. Trisomy 21
• C. Cleft lip
• D. Atrial septal defect

Correct answer: A

Rationale: The nurse should educate clients that inadequate folic acid intake is associated with an increased risk of neural tube defects in newborns. Consuming an adequate amount of folic acid from sources like fortified cereals, oranges, artichokes, liver, broccoli, and asparagus can help prevent this serious fetal abnormality. Trisomy 21 (Choice B) is caused by an extra chromosome 21 and is not preventable by folic acid intake. Cleft lip (Choice C) and atrial septal defect (Choice D) are not directly linked to folic acid intake during pregnancy.

3. A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?

• A. Encourage the parents to touch and explore the newborn's features
• B. Limit noise and interruptions in the delivery room
• C. Place the newborn at the client's breast
• D. Position the newborn skin-to-skin on the client's chest

Correct answer: D

Rationale: Positioning the newborn skin-to-skin on the client's chest is the priority action to promote warmth, regulate the newborn's heart rate and breathing, and enhance parent-infant bonding. This method facilitates early bonding, stabilizes the baby's temperature, and encourages breastfeeding initiation. Encouraging parents to touch and explore the newborn's features is important but not the priority at this moment. Limiting noise and interruptions can be beneficial but not as crucial as skin-to-skin contact for bonding. Placing the newborn at the client's breast is essential for breastfeeding but should come after the initial skin-to-skin contact for bonding and temperature regulation.

4. In a prenatal clinic, a client in the first trimester of pregnancy has a health record that includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply)

• A. Client has delivered one newborn at term
• B. Client has experienced no preterm labor
• C. Client has had two prior pregnancies
• D. ALL OF THE ABOVE - has one living child

Correct answer: D

Rationale: The client's health record data is interpreted as follows: G3 (gravida 3 - total number of pregnancies), T1 (term births - number of full-term deliveries), P0 (preterm births - number of preterm deliveries), A1 (abortions/miscarriages - total number of miscarriages or abortions), L1 (living children - total number of living children). Therefore, the client has had three pregnancies, one full-term delivery, no preterm labor, one miscarriage/abortion, and one living child. The correct interpretation is that the client has delivered one newborn at term, experienced no preterm labor, had two prior pregnancies, and has one living child. Therefore, choice D is correct. Choices A, B, and C are incorrect as they do not provide a comprehensive interpretation of all aspects of the client's health record data.

5. During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

• A. Maternal fever
• B. Fetal heart failure
• C. Maternal hypoglycemia
• D. Fetal head compression

Correct answer: A

Rationale: Maternal fever can lead to fetal tachycardia due to the transmission of maternal fever to the fetus. This can result in an increased fetal heart rate, making it the correct potential cause in this scenario. Fetal heart failure (choice B) would typically present with bradycardia rather than tachycardia, making it an incorrect choice. Maternal hypoglycemia (choice C) is more likely to cause fetal distress rather than tachycardia. Fetal head compression (choice D) may lead to decelerations in the fetal heart rate pattern, but not necessarily tachycardia.

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