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 healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

• A. 22/min
• B. 48/min
• C. 100/min
• D. 110/min

Correct answer: B

Rationale: The expected respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48 breaths per minute falls within this range, indicating normal respiratory function for a newborn. Choice A (22/min) is below the expected range, Choices C (100/min) and D (110/min) are above the expected range for a newborn's respiratory rate.

3. While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

• A. Place the client in the Trendelenburg position
• B. Apply finger pressure to the presenting part
• C. Administer oxygen at 10 L/min via a non-rebreather
• D. Call for assistance

Correct answer: D

Rationale: In the scenario of umbilical cord prolapse during labor, the nurse should first call for assistance. Umbilical cord prolapse is a critical obstetric emergency that requires immediate attention and skilled assistance. Calling for help ensures that additional support is on the way to provide prompt intervention. Placing the client in the Trendelenburg position (Choice A) is no longer recommended as it may worsen the situation. Applying finger pressure to the presenting part (Choice B) can further compress the cord. Administering oxygen (Choice C) is important but should come after addressing the prolapsed cord.

4. A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

• A. Maintain the client in the lithotomy position.
• B. Perform vaginal examinations frequently.
• C. Remind the client to bear down with each contraction.
• D. Encourage the client to empty her bladder every 2 hours.

Correct answer: D

Rationale: Encouraging the client to empty her bladder every 2 hours is essential during labor to prevent bladder distention, which can hinder labor progress and cause discomfort. A distended bladder can also lead to potential complications such as uterine atony or increased risk of infection. Choice A is incorrect as maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor and may not be comfortable for the client. Choice B is incorrect because performing vaginal examinations frequently can increase the risk of introducing infection and disrupt the natural progress of labor. Choice C is incorrect as bearing down with each contraction is typically reserved for the second stage of labor when the cervix is fully dilated, not during the active phase of the first stage.

5. A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)

• A. Breast tenderness
• B. Urinary frequency
• C. Epistaxis
• D. All of the above

Correct answer: D

Rationale: During early pregnancy, common discomforts include breast tenderness due to hormonal changes, urinary frequency caused by increased blood flow to the kidneys, and epistaxis (nosebleeds) due to increased blood volume and hormonal changes. Educating the client about these discomforts helps them understand what to expect during this stage. Choice D, 'All of the above,' is the correct answer because all the listed findings are common discomforts experienced during early pregnancy. Choices A, B, and C are individually correct as well, as breast tenderness, urinary frequency, and epistaxis are all common discomforts that pregnant individuals may encounter.

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