Nursing Elites

1. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?

• A. Initiate an intravenous infusion.
• B. Observe the FHR pattern for 30 more minutes.
• C. Schedule a biophysical profile.
• D. Place an acoustic stimulator on the abdomen.

Correct answer: D

Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.

2. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the

• A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
• B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
• C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
• D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

Correct answer: D

Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.

3. During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?

• A. Obtain blood and urine for prenatal screens.
• B. Schedule prenatal visits to occur monthly.
• C. Explain common complications of pregnancy.
• D. Obtain baseline blood pressure and weight.

Correct answer: A

Rationale: Obtaining blood and urine for prenatal screens is crucial in identifying any potential infections or conditions that may require monitoring throughout the pregnancy. Screening for infections such as syphilis is essential to ensure appropriate management and prevent adverse outcomes. This action helps in early detection and timely intervention, promoting the health and well-being of both the mother and the developing fetus. The other options, while important during prenatal care, are not as critical as obtaining prenatal screens to assess for any existing infections that could impact the pregnancy.

4. During an examination for possible cryptorchidism in an infant, what technique should be used?

• A. Place the infant in a warm room and use a calm approach.
• B. Hold the scrotum and palpate gently.
• C. Cleanse the penis with an antiseptic-soaked pad.
• D. Position the infant in a warm room to prevent muscle contraction.

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

5. The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition?

• A. Gestational diabetes.
• B. Elevated blood pressure.
• C. Urinary tract infection.
• D. Swelling in lower extremities.

Correct answer: A

Rationale: The correct answer is A: Gestational diabetes. Terbutaline (Brethine) is known to cause hyperglycemia, so it is crucial to assess for gestational diabetes before administering it. Assessing for elevated blood pressure (choice B), urinary tract infection (choice C), or swelling in lower extremities (choice D) is not directly related to the potential side effect of terbutaline in causing hyperglycemia.

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