Nursing Elites

1. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse’s highest priority in this situation?

• A. Prepare the woman for imminent birth.
• B. Notify the woman’s primary healthcare provider.
• C. Document the characteristics of the fluid.
• D. Assess the fetal heart rate (FHR) and pattern.

Correct answer: D

Rationale: The correct answer is to assess the fetal heart rate (FHR) and pattern (Choice D). When a multiparous woman's membranes rupture after 8 hours of labor, the nurse's priority is to assess the fetal well-being. Rupture of membranes can lead to potential complications such as umbilical cord prolapse. Monitoring the fetal heart rate and pattern immediately after the rupture of membranes is crucial to ensure the fetus is not in distress. This assessment helps in determining the need for immediate interventions to safeguard the fetus. Documenting the characteristics of the fluid (Choice C) may be necessary but is of lower priority compared to assessing fetal well-being. While preparing the woman for imminent birth (Choice A) is important, assessing the fetal heart rate takes precedence to ensure the fetus is not compromised. Notifying the woman's primary healthcare provider (Choice B) is also important but not the highest priority at this moment.

2. In the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old infant has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

• A. Provide blow-by oxygen
• B. Provide a capillary blood glucose test
• C. Draw arterial blood gases
• D. Apply a pulse oximeter to the foot

Correct answer: B

Rationale: Late preterm infants, such as those with a gestational age of 42 weeks, are at higher risk for hypoglycemia due to immature metabolic regulation. Monitoring capillary blood glucose is crucial to detect and manage hypoglycemia promptly. Providing blow-by oxygen (Choice A) is not indicated for an infant at risk for hypoglycemia. Drawing arterial blood gases (Choice C) is not the primary intervention for assessing hypoglycemia. Applying a pulse oximeter to the foot (Choice D) is not directly related to monitoring blood glucose levels in this context.

3. At 31 weeks gestation, a client with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide?

• A. Assessment for congenital anomalies
• B. Recalculation of gestational age
• C. Evaluation of fetal growth
• D. Determination of fetal presentation

Correct answer: C

Rationale: The correct answer is C: 'Evaluation of fetal growth.' A fundal height measurement smaller than expected may indicate intrauterine growth restriction (IUGR), requiring serial ultrasounds to monitor fetal growth. Assessing for congenital anomalies (choice A) is usually done through detailed anatomy scans earlier in pregnancy. Recalculating gestational age (choice B) is typically unnecessary at this stage unless there are concerns about accuracy. Determining fetal presentation (choice D) is usually done closer to term to plan for the mode of delivery.

4. The actual sets of traits that people exhibit are called their genotypes.

• A. TRUE
• B. FALSE
• C. Possibly
• D. Always

Correct answer: B

Rationale: The actual sets of traits that people exhibit are called phenotypes, not genotypes. Genotypes refer to the genetic makeup of an individual.

5. A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?

• A. Tinnitus
• B. Urinary Frequency
• C. Breast Tenderness
• D. Chills

Correct answer: C

Rationale: The correct answer is C: 'Breast Tenderness.' Clomiphene citrate is known to cause breast tenderness as a common side effect due to its hormonal effects on the body. Tinnitus (choice A), which is a ringing in the ears, is not typically associated with clomiphene citrate. Urinary frequency (choice B) is not a common adverse effect of this medication. Chills (choice D) are also not commonly linked to clomiphene citrate use.

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