Nursing Elites

1. Which statement by the client will assist the healthcare provider in determining whether she is in true labor as opposed to false labor?

• A. I passed some thick, pink mucus when I urinated this morning.
• B. My bag of waters just broke.
• C. The contractions in my uterus are getting stronger and closer together.
• D. My baby dropped, and I have to urinate more frequently now.

Correct answer: C

Rationale: The correct answer is C. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Choice A indicates the passing of the mucus plug, which is a sign of early labor but not definitive for true labor. Choice B, the breaking of the bag of waters, is a sign of labor but does not confirm whether it is true or false labor. Choice D, the baby dropping and increased urination frequency, suggests lightening, a sign that labor may be approaching, but it does not confirm true labor.

2. A newborn who was born post-term is being assessed by a nurse. Which of the following findings should the nurse expect?

• A. A Rh-negative mother who has an Rh-positive infant
• B. A Rh-positive mother who has an Rh-negative infant
• C. A Rh-positive mother who has an Rh-positive infant
• D. A Rh-negative mother who has an Rh-negative infant

Correct answer: A

Rationale: The correct answer is A: 'A Rh-negative mother who has an Rh-positive infant.' In cases where the newborn is born post-term, the mismatched Rh factor between the mother (Rh-negative) and the infant (Rh-positive) can lead to hemolytic disease of the newborn. This condition occurs when maternal antibodies attack fetal red blood cells, causing hemolysis. This can result in jaundice, anemia, and other serious complications for the infant. Choices B, C, and D are incorrect because they do not reflect the mismatched Rh factor scenario that poses a risk for hemolytic disease of the newborn.

3. Why is a client with gestational diabetes being scheduled for an amniocentesis when the fetus has an estimated weight of eight pounds (3629 grams) at 36 weeks gestation? What information is the amniocentesis seeking to obtain?

• A. Presence of a neural tube defect.
• B. Chromosomal abnormalities.
• C. Gender of the fetus.
• D. Fetal lung maturity.

Correct answer: D

Rationale: An amniocentesis in this scenario is most likely being performed to assess fetal lung maturity. This is necessary when considering early delivery due to macrosomia (large fetal size), which is a common concern in gestational diabetes. Evaluating fetal lung maturity is crucial to determine if the fetus's lungs are developed enough to support breathing independently outside the womb. The presence of a neural tube defect and chromosomal abnormalities are not typically assessed through amniocentesis in this situation, and determining the gender of the fetus is not the primary purpose of the procedure here.

4. Rubella, also called German measles, is a viral infection passed from the mother to the fetus that can cause birth defects such as deafness, intellectual disabilities, blindness, and heart disease in the embryo.

• A. Rubella
• B. Syphilis
• C. Cystic fibrosis
• D. Phenylketonuria

Correct answer: A

Rationale: Rubella, also known as German measles, is a viral infection that can lead to severe birth defects when contracted by a mother during pregnancy. Rubella is the correct answer because it is specifically associated with causing birth defects such as deafness, intellectual disabilities, blindness, and heart disease in the embryo. Syphilis (Choice B) can be passed from mother to fetus but does not cause the mentioned birth defects associated with Rubella. Cystic fibrosis (Choice C) and Phenylketonuria (Choice D) are genetic conditions and not infections transmitted from mother to fetus, making them incorrect choices in this context.

5. 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.

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