Nursing Elites

1. What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

• A. Assessing the strength of uterine contractions
• B. Re-evaluating the need for medication
• C. Reminding her to push 3 times with each contraction
• D. Assisting her to maintain control

Correct answer: D

Rationale: During the transitional phase of labor, which is the most intense phase, the primary focus of nursing care for a client who anticipates an unmedicated delivery should be assisting her to maintain control. This is essential to help her manage the intense pain and anxiety associated with this phase without the use of medication. Assessing the strength of uterine contractions (Choice A) is important but not the primary focus during the transitional phase. Re-evaluating the need for medication (Choice B) is not applicable as the client anticipates an unmedicated delivery. Reminding her to push 3 times with each contraction (Choice C) is more related to the pushing stage of labor and not the transitional phase.

2. After a mother was diagnosed with gonorrhea immediately after delivery, what is an important goal of the nurse when providing care for her baby?

• A. Prevent the development of ophthalmia neonatorum.
• B. Lubricate the eyes.
• C. Prevent the development of infection.
• D. Teach about the risks of breastfeeding with gonorrhea.

Correct answer: A

Rationale: The correct answer is A: Prevent the development of ophthalmia neonatorum. When a mother has gonorrhea, the baby can be infected during delivery, leading to ophthalmia neonatorum, which can cause permanent blindness. Therefore, it is crucial for the nurse to prevent this condition by treating the baby's eyes with an antibiotic prophylactically after birth. Choice B, lubricating the eyes, is not the primary goal in this situation as preventing infection takes precedence. Choice C, preventing the development of infection, is too broad and does not specifically address the potential complication of ophthalmia neonatorum. Choice D, teaching about the risks of breastfeeding with gonorrhea, is important but not the immediate goal in this scenario where preventing ophthalmia neonatorum and potential blindness is the priority.

3. Which of the following conditions is considered a multifactorial problem?

• A. Cystic fibrosis
• B. Down syndrome
• C. Diabetes mellitus
• D. XYY syndrome

Correct answer: C

Rationale: The correct answer is 'Diabetes mellitus' because it is a multifactorial disease, influenced by both genetic predisposition and environmental factors. Cystic fibrosis (choice A) is primarily a genetic disorder caused by mutations in the CFTR gene. Down syndrome (choice B) is due to an extra copy of chromosome 21. XYY syndrome (choice D) is a genetic condition where males have an extra Y chromosome. These conditions are not considered multifactorial as their origins are primarily genetic.

4. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

• A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
• B. Risk for altered gas exchange.
• C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
• D. Risk for increased cardiac output, related to the use of antihypertensive drugs.

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.

5. Which of the following is a fatal genetic neurologic disorder whose onset is in middle age?

• A. Tay-Sachs disease
• B. Duchenne muscular dystrophy
• C. Hemophilia
• D. Huntington’s disease

Correct answer: D

Rationale: Huntington's disease is a fatal genetic neurologic disorder characterized by progressive nerve cell degeneration in the brain. It typically manifests in middle age with symptoms such as involuntary movements, cognitive decline, and psychiatric disturbances. Tay-Sachs disease (Choice A) is a genetic disorder that primarily affects the nervous system in early childhood, not middle age. Duchenne muscular dystrophy (Choice B) is a genetic disorder that primarily affects muscle function and usually presents in early childhood. Hemophilia (Choice C) is a genetic disorder related to blood clotting, and its onset is not typically in middle age.

Similar Questions