Nursing Elites

1. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?

• A. Do you have any active lesions?
• B. Have your membranes ruptured?
• C. How far apart are your contractions?
• D. Are you positive for beta strep?

Correct answer: A

Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.

2. A client gave birth 4 hours ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?

• A. Elevate the client's legs to a 30° angle
• B. Insert an indwelling urinary catheter
• C. Massage the client's fundus
• D. Initiate an infusion of oxytocin

Correct answer: C

Rationale: The correct answer is to massage the client's fundus first. Uterine atony is a common cause of postpartum hemorrhage, and massaging the fundus can help stimulate uterine contractions, which will assist in reducing bleeding. Elevating the client's legs to a 30° angle (Choice A) is not the priority in this situation as fundal massage takes precedence. Inserting an indwelling urinary catheter (Choice B) may be necessary but should not take precedence over managing the postpartum hemorrhage. Initiating an infusion of oxytocin (Choice D) is a valid intervention to address uterine atony, but massaging the fundus should come first to promote immediate contraction and control bleeding.

3. A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?

• A. Cephalohematoma
• B. Caput succedaneum
• C. Subdural hematoma
• D. Molding

Correct answer: A

Rationale: The correct answer is A, cephalohematoma. A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It is caused by trauma during birth and typically resolves on its own. Choice B, caput succedaneum, is characterized by diffuse edema over a newborn's scalp that crosses suture lines. Choice C, subdural hematoma, is a more serious condition involving bleeding between the dura mater and the brain. Choice D, molding, refers to the shaping of the fetal head during passage through the birth canal. Therefore, the nurse should document cephalohematoma in this scenario as it aligns with the description of a soft, swollen area on the newborn's scalp that does not cross the suture line.

4. A client presents with symptoms suggestive of rheumatoid arthritis. Which of the following laboratory tests should be ordered to confirm this diagnosis?

• A. Erythrocyte sedimentation rate (ESR)
• B. Rheumatoid factor
• C. Antinuclear antibody
• D. Serum calcium

Correct answer: B

Rationale: Rheumatoid factor is a specific marker for rheumatoid arthritis. It is often elevated in clients with this autoimmune condition, helping to confirm the diagnosis. Erythrocyte sedimentation rate (ESR) and antinuclear antibody tests can be supportive but are not specific for rheumatoid arthritis. Serum calcium levels are not typically used to confirm this diagnosis.

5. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?

• A. That’s not a good idea; the surgery is necessary
• B. Share with me more about the thoughts that are concerning you
• C. You should trust your doctor’s advice
• D. You can always reschedule the surgery later

Correct answer: B

Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.

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