Nursing Elites

1. A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?

• A. This test screens for neural tube defects and other developmental abnormalities in the fetus.
• B. It assesses various markers of fetal well-being.
• C. This test identifies an Rh incompatibility between the mother and fetus.
• D. It is a screening test for spinal defects in the fetus.

Correct answer: A

Rationale: The maternal serum alpha-fetoprotein (MSAFP) test is performed around 15-18 weeks of gestation to screen for neural tube defects and other developmental abnormalities in the fetus, not to assess fetal lung maturity, markers of fetal well-being, or Rh incompatibility between the mother and fetus. Choice A is the correct answer as it accurately reflects the purpose of the MSAFP test. Choices B, C, and D are incorrect because they do not align with the primary goal of this screening test.

2. A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

• A. Heart rate 168/min
• B. Respiratory rate 18/min
• C. Tremors
• D. Fine crackles

Correct answer: B

Rationale: A newborn's respiratory rate can vary between 20 to 100 breaths per minute during the initial phase after birth. A respiratory rate as low as 18 breaths per minute at this early stage requires immediate nursing intervention. This finding necessitates further assessment to ensure adequate oxygenation and respiratory function. The other options, heart rate of 168/min, tremors, and fine crackles, are within normal limits for a full-term newborn and do not require immediate intervention.

3. A healthcare provider is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the provider expect? (Select all that apply)

• A. Chadwick's sign
• B. Goodell's sign
• C. Ballottement
• D. All of the above

Correct answer: D

Rationale: Chadwick's sign, Goodell's sign, and ballottement are probable signs of pregnancy. Chadwick's sign refers to a bluish discoloration of the cervix and vaginal mucosa. Goodell's sign is the softening of the cervix due to increased vascularity. Ballottement is the rebound of the fetus when the cervix is tapped during a vaginal examination. Recognizing these signs is essential for healthcare providers in assessing pregnancy. Therefore, all of the above choices are correct as they are all probable signs of pregnancy. Choice D is the correct answer as it includes all the expected findings.

4. 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.

5. When assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?

• A. Oxygen saturation
• B. Body temperature
• C. Serum bilirubin
• D. Heart rate

Correct answer: A

Rationale: In a newborn with respiratory distress syndrome who has received synthetic surfactant, monitoring oxygen saturation is crucial to evaluate the effectiveness of the treatment. Oxygen saturation levels provide valuable information about the newborn's respiratory status and the adequacy of gas exchange. Changes in oxygen saturation can indicate improvements or deterioration in the newborn's condition following the administration of synthetic surfactant. Monitoring oxygen saturation helps the nurse assess the newborn's response to treatment and make timely interventions if needed. Body temperature, serum bilirubin, and heart rate are important parameters to monitor in newborns for other conditions but are not specific indicators of the effectiveness of synthetic surfactant in treating respiratory distress syndrome.

Similar Questions