Nursing Elites

1. The client who is 40 weeks gestation seems upset and tells the nurse that the physician told her she needs to have a nonstress test. The client asks why she needs the test. The nurse’s best response would be:

• A. This is a test to see if your stress level is affecting your baby’s growth and well-being.
• B. This is a test to see if your baby will be able to withstand the stress of labor.
• C. This is a test to assess your baby’s well-being now that you are due to deliver soon.
• D. This is a test to let us know if your baby needs to be delivered to avoid a bad outcome.

Correct answer: C

Rationale: The correct response is C because the nonstress test is specifically used to assess the baby's well-being close to the due date. It helps determine if the baby is receiving enough oxygen and nutrients in the womb. Choice A is incorrect as the test does not assess the mother's stress level but focuses on fetal well-being. Choice B is incorrect as the test does not predict the baby's ability to withstand labor. Choice D is incorrect because the test does not solely indicate if the baby needs to be delivered to avoid a bad outcome; rather, it assesses the current well-being of the baby.

2. A healthcare provider is reviewing laboratory results for a client who is pregnant. The healthcare provider should expect which of the following laboratory values to increase?

• A. RBC count
• B. Bilirubin
• C. Fasting blood glucose
• D. BUN

Correct answer: A

Rationale: During pregnancy, the body increases the production of red blood cells (RBCs) to meet the increased oxygen demands. This physiological response is known as physiological anemia of pregnancy. Therefore, the RBC count is expected to increase during pregnancy. Bilirubin levels may remain relatively stable, fasting blood glucose levels might fluctuate due to gestational diabetes, and blood urea nitrogen (BUN) levels are not typically affected by pregnancy, making them less likely to increase in this scenario. The correct answer is A because an increase in RBC count is a normal physiological adaptation to pregnancy to support the increased oxygen needs of the mother and the growing fetus. Bilirubin, a product of red blood cell breakdown, is more related to liver function and not expected to increase during pregnancy. Fasting blood glucose levels may vary due to gestational diabetes, but it is not a consistent finding in all pregnant individuals. BUN levels are related to kidney function and are not typically impacted by pregnancy, making it an unlikely choice for an expected increase in laboratory values during pregnancy.

3. When reviewing the electronic medical record of a postpartum client, which of the following factors places the client at risk for infection?

• A. Meconium-stained amniotic fluid
• B. Placenta previa
• C. Midline episiotomy
• D. Gestational hypertension

Correct answer: C

Rationale: The correct answer is C: Midline episiotomy. An episiotomy is a surgical incision made during childbirth to enlarge the vaginal opening. This procedure increases the risk of infection in the postpartum period due to the incision site being a potential entry point for pathogens. Meconium-stained amniotic fluid (choice A) is a risk factor for fetal distress but does not directly increase the mother's risk of infection. Placenta previa (choice B) is a condition where the placenta partially or completely covers the cervix, leading to potential bleeding issues but not necessarily an increased risk of infection. Gestational hypertension (choice D) is a hypertensive disorder that affects some pregnant women but is not directly associated with an increased risk of infection in the postpartum period.

4. Is color blindness a sex-linked abnormality?

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

Correct answer: A

Rationale: The correct answer is A: TRUE. Color blindness is indeed a sex-linked abnormality as it is often associated with genes on the X chromosome. Since males have only one X chromosome, they are more likely to inherit color blindness if the gene is present. This makes color blindness more common in males. Choice B (FALSE) is incorrect because color blindness is linked to the X chromosome. Choices C (Sometimes) and D (Always) are incorrect as color blindness is consistently tied to the X chromosome.

5. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

• A. Administer oxygen by mouth at 2L/min
• B. Gradually warm the infant under a radiant heat source
• C. Notify the pediatrician of the infant's vital signs
• D. Perform a heel-stick to maintain blood glucose levels

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.

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