Nursing Elites

1. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

• A. Check the client's temperature.
• B. Observe for uterine contractions.
• C. Administer Rho(D) immune globulin.
• D. Monitor the fetal heart rate (FHR).

Correct answer: D

Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.

2. A client who is at 24 weeks of gestation is scheduled for a 1-hour glucose tolerance test. Which of the following statements should the nurse include in her teaching?

• A. You will need to drink the glucose solution 1 hour prior to the test.
• B. Limit your carbohydrate intake for 24 hours prior to the test.
• C. A blood glucose of 130 to 140 mg/dL is considered a positive screening result.
• D. You will need to fast for 8 hours prior to the test.

Correct answer: C

Rationale: The correct statement to include in the teaching for a client scheduled for a 1-hour glucose tolerance test at 24 weeks of gestation is that a blood glucose level of 130 to 140 mg/dL is considered a positive screening result. This range indicates a potential issue with glucose metabolism and would prompt the need for a follow-up 3-hour glucose tolerance test to confirm the diagnosis of gestational diabetes mellitus. Choices A, B, and D are incorrect. In a 1-hour glucose tolerance test, the glucose solution is typically consumed within a specific timeframe before the test, not necessarily 1 hour prior. There is usually no specific requirement to limit carbohydrate intake for 24 hours prior to the test. Fasting for 8 hours prior to the test is more common for a fasting glucose test, not a 1-hour glucose tolerance test.

3. A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?

• A. Bruising over the buttocks
• B. Hard nodules on the roof of the mouth
• C. Petechiae over the head
• D. Bilateral periauricular papillomas

Correct answer: C

Rationale: When a newborn experiences a tight nuchal cord during delivery, it can lead to petechiae, which are small red or purple spots on the skin caused by bleeding under the skin. These petechiae may appear over the head, face, and neck due to the pressure of the cord. It is essential for the nurse to recognize this as a possible consequence and monitor the newborn for any signs of complications. Bruising over the buttocks (Choice A) is not typically associated with a tight nuchal cord. Hard nodules on the roof of the mouth (Choice B) are more indicative of Epstein pearls or Bohn's nodules, which are considered normal findings in newborns. Bilateral periauricular papillomas (Choice D) are not related to a tight nuchal cord but are seen in congenital syphilis.

4. When reinforcing teaching with a group of new parents about proper techniques for bottle feeding, which of the following instructions should be provided?

• A. Burp the newborn at the end of the feeding
• B. Hold the newborn close in a supine position
• C. Keep the nipple full of formula throughout the feeding
• D. Refrigerate any unused formula

Correct answer: C

Rationale: The correct technique for bottle feeding includes keeping the nipple full of formula throughout the feeding to prevent air from entering the baby's stomach. This helps reduce the risk of the baby swallowing air, which can lead to discomfort and colic. Therefore, maintaining a full nipple during feeding is essential for the baby's comfort and digestion. Option A is incorrect as burping should be done during the feeding to prevent excessive air intake. Option B is incorrect as the baby should be held semi-upright, not in a supine position, to reduce the risk of choking and ear infections. Option D is irrelevant to the feeding process and does not contribute to the baby's well-being.

5. When providing care for a client in preterm labor at 32 weeks of gestation, which medication should the nurse anticipate the provider will prescribe to hasten fetal lung maturity?

• A. Calcium gluconate
• B. Indomethacin
• C. Nifedipine
• D. Betamethasone

Correct answer: D

Rationale: Betamethasone is the correct medication to anticipate the provider prescribing to hasten fetal lung maturity in clients at risk for preterm labor. It is a corticosteroid that helps promote lung maturation in the preterm fetus by stimulating the production of surfactant, which is essential for lung function. This medication is commonly given to pregnant individuals at risk of preterm delivery between 24 and 34 weeks of gestation to reduce the risk of respiratory distress syndrome in the newborn. Calcium gluconate, Indomethacin, and Nifedipine are not used to hasten fetal lung maturity in preterm labor; they serve different purposes in maternal and fetal care.

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