Nursing Elites

1. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?

• A. Caput succedaneum
• B. Hydrocephalus
• C. Cephalhematoma
• D. Microcephaly

Correct answer: C

Rationale: The correct answer is Cephalhematoma. Cephalhematoma is a collection of blood between the skull bone and periosteum that does not cross the suture line. It often occurs due to birth trauma, such as forceps delivery, leading to localized swelling. Caput succedaneum (Choice A) is diffuse swelling of the scalp that may cross suture lines and is typically present at birth. Hydrocephalus (Choice B) is an abnormal accumulation of cerebrospinal fluid within the brain's ventricles. Microcephaly (Choice D) is a condition characterized by a smaller than average head size and may be present at birth or develop later in infancy.

2. When should the low-risk patient, who is 16 weeks pregnant, be advised to return to the prenatal clinic?

• A. 1 week.
• B. 2 weeks.
• C. 3 weeks.
• D. 4 weeks.

Correct answer: D

Rationale: The correct answer is D: 4 weeks. Low-risk pregnant patients typically have prenatal visits every 4 weeks until 28 weeks of gestation. This frequency allows for adequate monitoring of the pregnancy without being overly burdensome on the patient. Choices A, B, and C are incorrect as they do not align with the standard prenatal care schedule for low-risk pregnancies. Visits that are too frequent may cause unnecessary anxiety for the patient, while visits that are too infrequent may miss important opportunities for monitoring and intervention.

3. Which of the following statements about Rh incompatibility is true?

• A. Rh incompatibility occurs most commonly during a woman’s first pregnancy.
• B. Rh incompatibility is an untreatable condition that leaves a woman infertile for the rest of her life.
• C. Rh incompatibility is an abnormality that is transmitted from generation to generation and carried by a sex chromosome.
• D. Rh incompatibility occurs due to antibodies transmitted to a fetus during subsequent deliveries causing brain damage or death.

Correct answer: D

Rationale: Rh incompatibility occurs when the mother's antibodies attack the fetus's red blood cells, leading to serious complications, usually in subsequent pregnancies. Choice A is incorrect because Rh incompatibility often occurs in subsequent pregnancies, not necessarily the first one. Choice B is incorrect as Rh incompatibility does not render a woman infertile but can lead to complications during pregnancies. Choice C is incorrect as Rh incompatibility is not carried by a sex chromosome but involves the Rh factor on red blood cells.

4. The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right. She tells the nurse, "Now my daughter is not getting enough to eat." Which response would be best for the nurse to make?

• A. Feed your baby hourly until you feel confident that your child is receiving enough milk.
• B. Don't worry, soon your milk will come in, and you will feel how full your breasts are.
• C. Since you are so concerned, you should probably supplement breastfeeding with formula.
• D. If your baby's urine is straw-colored, she's getting enough milk.

Correct answer: D

Rationale: Reassuring the mother that the baby's urine color can be an indicator of adequate hydration can help her feel more confident in her breastfeeding.

5. What is the central layer of the embryo from which the bones and muscles develop?

• A. neural tube
• B. mesoderm
• C. ectoderm
• D. umbilical cord

Correct answer: B

Rationale: The correct answer is mesoderm. The mesoderm is the middle layer of the embryo that gives rise to the bones, muscles, and other connective tissues. The neural tube (choice A) develops into the nervous system, not bones and muscles. The ectoderm (choice C) forms the skin and nervous system, not bones and muscles. The umbilical cord (choice D) is a structure that connects the developing fetus to the placenta; it is not a layer of the embryo that gives rise to bones and muscles.

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