Nursing Elites

1. A client at 20 weeks of gestation has trichomoniasis. Which of the following findings should the nurse expect?

• A. Thick, White Vaginal Discharge
• B. Urinary Frequency
• C. Vulvar Lesions
• D. Malodorous Discharge

Correct answer: D

Rationale: Malodorous discharge is a common symptom of trichomoniasis caused by the Trichomonas vaginalis parasite. It is typically described as frothy, greenish-yellow, and malodorous. Choices A, B, and C are incorrect findings associated with other conditions. Thick, white vaginal discharge is more characteristic of a yeast infection; urinary frequency may be seen in urinary tract infections; and vulvar lesions are commonly seen in herpes simplex virus infections.

2. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?

• A. Page the pediatrician STAT
• B. Continue resuscitative efforts
• C. Repeat the Apgar assessment in 5 minutes
• D. Inform the parents of the infant's condition

Correct answer: B

Rationale: In a situation where an infant receives a low Apgar score of 3 following a traumatic delivery, the most crucial intervention for the nurse to implement is to continue resuscitative efforts. A low Apgar score indicates that the newborn is in distress and requires immediate medical attention to support breathing, heart rate, muscle tone, reflex irritability, and color. Continuing resuscitative efforts is essential to provide life-saving interventions promptly. Paging the pediatrician may cause a delay in crucial interventions, repeating the Apgar assessment in 5 minutes is not appropriate as immediate action is needed to stabilize the infant, and informing parents should not take precedence over providing immediate medical care to the newborn.

3. The nurse is receiving a report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?

• A. Begin a pad count
• B. Prepare to start an IV
• C. Take the client's temperature
• D. Monitor amniotic fluid for meconium

Correct answer: C

Rationale: The priority nursing action when a client with ruptured membranes is admitted to the labor and delivery suite is to take the client's temperature. This is crucial to assess for infection, especially when the duration of membrane rupture is unknown. Beginning a pad count, preparing to start an IV, and monitoring amniotic fluid for meconium are important actions but are not as immediate or critical as assessing for infection through temperature measurement.

4. What is the central layer of the embryo from which the bones and muscles develop?

• A. neural tube
• B. mesoderm
• C. ectoderm
• D. umbilical cord

Correct answer: B

Rationale: The correct answer is mesoderm. The mesoderm is the middle layer of the embryo that gives rise to the bones, muscles, and other connective tissues. The neural tube (choice A) develops into the nervous system, not bones and muscles. The ectoderm (choice C) forms the skin and nervous system, not bones and muscles. The umbilical cord (choice D) is a structure that connects the developing fetus to the placenta; it is not a layer of the embryo that gives rise to bones and muscles.

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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