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. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

• A. Increase the infusion rate every 30 to 60 minutes.
• B. Maintain the client in a supine position.
• C. Titrate the infusion rate by 4 milliunits/min.
• D. Limit IV intake to 4 L per 24 hours.

Correct answer: A

Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.

3. A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?

• A. Blood pressure (BP) increased to 138/86 mm Hg.
• B. Weight gain of 0.5 kg during the past 2 weeks.
• C. Dipstick value of 3+ for protein in her urine.
• D. Pitting pedal edema at the end of the day.

Correct answer: C

Rationale: The correct answer is C. Proteinuria, indicated by a dipstick value of 3+ in the urine, is a significant concern in a patient being monitored for preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, and a value of 3+ signifies a substantial amount of protein in the urine, warranting further evaluation. While an increase in blood pressure to 138/86 mm Hg is slightly elevated, it does not meet the diagnostic threshold for severe hypertension in preeclampsia. A weight gain of 0.5 kg over 2 weeks is within normal limits and not as concerning as significant rapid weight gain. Pitting pedal edema, though common in pregnancy, is not a specific indicator of preeclampsia and is considered a less concerning finding compared to significant proteinuria.

4. A newborn is 24 hours old, and a healthcare provider is caring for them. Which of the following laboratory findings should the healthcare provider report to the provider?

• A. Hgb 20 g/dL
• B. Bilirubin 2 mg/dL
• C. Platelets 200,000/mm3
• D. WBC count 32,000/mm3

Correct answer: D

Rationale: The correct answer is D: WBC count 32,000/mm3. A WBC count of 32,000/mm3 is significantly elevated in a newborn and could indicate an infection, which needs immediate attention and intervention. High white blood cell counts in newborns can be concerning as they may suggest an ongoing infection or other underlying issues that require prompt medical evaluation and treatment. Choices A, B, and C are within normal ranges for a newborn and would not typically warrant immediate reporting to the provider. Hgb levels of 20 g/dL (Choice A) are high for newborns, but this is not as concerning as a significantly elevated WBC count. Bilirubin levels of 2 mg/dL (Choice B) are within normal limits for a newborn and do not indicate immediate issues. Platelet count of 200,000/mm3 (Choice C) is also within the normal range for a newborn and would not require immediate reporting.

5. When discussing risk factors for gestational diabetes mellitus (GDM) with a group of pregnant clients, which ethnicity should the nurse identify as having the lowest incidence of GDM?

• A. Asian
• B. Non-Hispanic White American
• C. Hispanic
• D. African American

Correct answer: B

Rationale: Non-Hispanic White Americans have the lowest incidence of gestational diabetes mellitus (GDM) compared to other ethnicities. This is because GDM is more prevalent among certain ethnic groups, such as Asian, Hispanic, and African American populations. Asian individuals have an increased risk of developing GDM due to genetic factors, while Hispanic and African American populations have higher incidences of GDM due to lifestyle and genetic predispositions. Therefore, the correct answer is B, as Non-Hispanic White Americans generally have a lower risk of developing GDM.

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