Nursing Elites

1. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?

• A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
• B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
• C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
• D. Record the findings on the chart. They are within normal limits.

Correct answer: D

Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.

2. Most victims of _____ die of respiratory infections in their 20s.

• A. Tay-Sachs disease
• B. cystic fibrosis
• C. Turner syndrome
• D. Klinefelter syndrome

Correct answer: B

Rationale: Individuals with cystic fibrosis have a genetic disorder that causes mucus to be thick and sticky, leading to blockages in the lungs and digestive system. This mucus buildup makes them more susceptible to severe respiratory infections, which can ultimately result in premature death in their 20s. Tay-Sachs disease (Choice A) is a genetic disorder that affects the nervous system, not typically causing respiratory infections. Turner syndrome (Choice C) and Klinefelter syndrome (Choice D) are chromosomal disorders that do not directly lead to the respiratory issues observed in cystic fibrosis.

3. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?

• A. Dilation of the cervix.
• B. Descent of the fetus to –2 station.
• C. Rupture of the amniotic membranes.
• D. Increase in bloody show.

Correct answer: A

Rationale: During the first stage of labor, effective uterine contractions lead to cervical dilation. Dilation of the cervix is a key indicator that uterine contractions are progressing labor. Descent of the fetus to -2 station (Choice B) is related to the fetal position in the pelvis and not a direct indicator of uterine contraction effectiveness. Rupture of the amniotic membranes (Choice C) signifies the rupture of the fluid-filled sac surrounding the fetus and does not directly reflect uterine contraction effectiveness. An increase in bloody show (Choice D) can be a sign of impending labor, but it is not a direct indicator of uterine contraction effectiveness.

4. A client is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?

• A. Blood pressure 142/92 mm Hg
• B. Urine output 100 mL in 1 hr
• C. Pulse 58/min
• D. Respiratory rate 14/min

Correct answer: A

Rationale: The correct answer is A. Methylergonovine can increase blood pressure, so it should be withheld if the client has hypertension. A blood pressure reading of 142/92 mm Hg indicates hypertension and is a contraindication for administering methylergonovine. Choices B, C, and D are within normal limits and not contraindications for administering this medication. Urine output, pulse rate, and respiratory rate are not factors that determine the appropriateness of administering methylergonovine in this situation.

5. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?

• A. A client who has diabetes mellitus and an HbA1c of 5.8%
• B. A client who has preeclampsia and a creatinine level of 1.1 mg/dL
• C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
• D. A client who has placenta previa and a hematocrit of 36%

Correct answer: C

Rationale: A sodium level of 110 mEq/L is critically low and can indicate severe dehydration and electrolyte imbalance, requiring immediate intervention.

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