Nursing Elites

1. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

• A. A client who has diabetes mellitus and an HbA1c of 5.8%
• B. A client who has preeclampsia and a creatinine level of 1.1 mg/dL
• C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
• D. A client who has placenta previa and a hematocrit of 36%

Correct answer: C

Rationale: A sodium level of 110 mEq/L is critically low and can indicate severe dehydration and electrolyte imbalance, requiring immediate intervention.

2. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?

• A. Assessing FHR and maternal vital signs.
• B. Performing a venipuncture for hemoglobin and hematocrit levels.
• C. Placing clean disposable pads to collect any drainage.
• D. Monitoring uterine contractions.

Correct answer: A

Rationale: The highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to assess the fetal heart rate (FHR) and maternal vital signs. This assessment is crucial in determining the extent of blood loss and its impact on both the mother and the fetus. Ensuring the well-being of both the mother and the fetus is the top priority in this situation. While obtaining hemoglobin and hematocrit levels is important, it can be done after the initial assessment. Placing clean disposable pads is necessary for managing any drainage but does not take precedence over assessing vital signs. Monitoring uterine contractions is important but is not the highest priority when compared to assessing the FHR and maternal vital signs.

3. Is Duchenne muscular dystrophy a sex-linked abnormality?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: A

Rationale: The correct answer is A: TRUE. Duchenne muscular dystrophy is an X-linked recessive disorder, primarily affecting males. This is due to the inheritance of the mutated gene on the X chromosome. Choices B, C, and D are incorrect because Duchenne muscular dystrophy is specifically classified as a sex-linked disorder affecting males due to the inheritance pattern.

4. The _________ is the hollow organ within females in which the embryo and fetus develop.

• A. placenta
• B. ovum
• C. uterus
• D. amniotic sac

Correct answer: C

Rationale: The correct answer is C: uterus. The uterus is the organ where the embryo implants and the fetus develops during pregnancy. The placenta (choice A) is an organ that develops during pregnancy and provides nutrients and oxygen to the fetus, but it is not the organ where the embryo and fetus physically develop. The ovum (choice B) is the female reproductive cell or egg that is fertilized by the sperm to form an embryo, but it is not the organ where the embryo and fetus develop. The amniotic sac (choice D) is a membrane filled with amniotic fluid that surrounds and protects the fetus, but it is not the organ where the embryo and fetus physically develop.

5. A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the healthcare provider?

• A. A pattern of fetal late decelerations.
• B. Fetal heart rate accelerations with fetal movement.
• C. Absence of uterine contractions within 20 minutes.
• D. Spontaneous rupture of membranes.

Correct answer: A

Rationale: The correct answer is A: A pattern of fetal late decelerations. Late decelerations during a contraction stress test are concerning as they indicate uteroplacental insufficiency, which can pose a risk to fetal well-being. Reporting this finding to the healthcare provider is crucial for prompt intervention. Choice B, fetal heart rate accelerations with fetal movement, is a reassuring sign of fetal well-being and does not raise immediate concerns. Choice C, absence of uterine contractions within 20 minutes, may require further assessment but is not as critical as late decelerations. Choice D, spontaneous rupture of membranes, is important but not the most immediate concern during a contraction stress test.

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