Nursing Elites

1. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?

• A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
• B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
• C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
• D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

Correct answer: B

Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.

2. 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.

3. As women reach the end of their childbearing years, does ovulation become more regular?

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

Correct answer: B

Rationale: The correct answer is B: FALSE. As women age and reach the end of their childbearing years, ovulation becomes less regular due to hormonal changes associated with menopause. This can result in irregular ovulation patterns or even the cessation of ovulation entirely. Choice A is incorrect because ovulation does not become more regular with age. Choices C and D are also incorrect as they do not accurately reflect the changes in ovulation patterns that occur as women approach the end of their childbearing years.

4. A client who is 5 days postpartum is being taught about signs of effective breastfeeding. Which information should the nurse include in the teaching?

• A. Feeling a tugging sensation when the baby is sucking
• B. Expecting the baby to have two to three wet diapers in a 24-hour period
• C. The baby’s urine should appear dark and concentrated
• D. The breast should stay firm after the baby breastfeeds

Correct answer: A

Rationale: Feeling a tugging sensation while the baby is sucking indicates an effective latch and milk transfer during breastfeeding. This sensation means that the baby is effectively drawing milk from the breast. Choice B is incorrect because infants should ideally have six to eight wet diapers in a 24-hour period to show adequate hydration. Choice C is incorrect as a dark and concentrated urine may indicate dehydration, which is not a sign of effective breastfeeding. Choice D is incorrect as the breast should soften after the baby breastfeeds, indicating that the baby has effectively emptied the breast of milk.

5. A nurse is reviewing laboratory results for a term newborn who is 24 hours old. Which of the following results require intervention by the nurse?

• A. WBC count 10,000/mm3
• B. Platelets 180,000/mm3
• C. Hemoglobin 20g/dL
• D. Glucose 20 mg/dL

Correct answer: D

Rationale: A glucose level of 20 mg/dL is critically low for a newborn and requires immediate intervention. Hypoglycemia in a newborn can lead to serious complications such as neurologic deficits. The normal range for glucose levels in a newborn is typically 40-60 mg/dL. Choices A, B, and C represent normal or acceptable values for a term newborn and do not require immediate intervention. A WBC count of 10,000/mm3, platelets of 180,000/mm3, and hemoglobin of 20g/dL are all within normal ranges for a term newborn and do not raise immediate concerns.

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