Nursing Elites

1. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2 if necessary.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary.

Correct answer: D

Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.

2. Which of the following terms refers to soft tissue injury caused by blunt force?

• A. contusion
• B. strain
• C. sprain
• D. dislocation

Correct answer: A

Rationale: A contusion is a soft tissue injury caused by blunt force. It is an injury that does not break the skin, caused by a blow, and characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition where the articular surfaces of the bones forming a joint are no longer in anatomical contact. Therefore, the correct answer is 'contusion' as it specifically relates to soft tissue injury caused by blunt force.

3. Which deficiency in the mother has been primarily associated with neural tube defects in the fetus?

• A. Iron
• B. Folic acid
• C. Vitamin B12
• D. Vitamin E

Correct answer: B

Rationale: Folic acid deficiency in the mother has been primarily associated with neural tube defects in the fetus. Folic acid is crucial for the development of the neural tube in the early stages of pregnancy. Its deficiency can lead to neural tube defects, such as spina bifida or anencephaly. Iron deficiency is not directly related to neural tube defects but can cause other complications in pregnancy. Vitamin B12 is important for neurological function but is not the primary cause of neural tube defects. Vitamin E deficiency is not associated with neural tube defects in the fetus.

4. What could be a possible cause for the symptoms experienced by the client in Question 28?

• A. iron deficiency
• B. folate deficiency
• C. peptic ulcer
• D. iron overload

Correct answer: A

Rationale: Given the client's symptoms of fatigue, shortness of breath, and lightheadedness, along with her gender and fad dieting, the most likely cause is iron deficiency. Iron deficiency commonly presents with these symptoms due to decreased oxygen-carrying capacity in the blood. Folate deficiency would typically present with different symptoms such as mouth sores and changes in skin, not fitting the client's presentation. Peptic ulcer would manifest with abdominal pain, not primarily with the symptoms described. Iron overload would present with symptoms such as joint pain and fatigue, which are not consistent with the client's presentation.

5. A patient has been ordered to receive Klonopin for the first time. Which of the following side effects is not associated with Klonopin?

• A. Drowsiness
• B. Ataxia
• C. Salivation elevation
• D. Diplopia

Correct answer: D

Rationale: The correct answer is 'Diplopia.' While drowsiness, ataxia, and salivation elevation are common side effects associated with Klonopin, diplopia is not typically linked to this medication. Diplopia, or double vision, is not a common side effect reported with the use of Klonopin. It is important to monitor patients for the known side effects such as drowsiness, ataxia, and salivation elevation when administering Klonopin. Choice A, B, and C are incorrect as they are known side effects of Klonopin, unlike diplopia which is not commonly observed with this medication.

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