Nursing Elites

1. A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

• A. Recheck the client’s temperature in 4 hours
• B. Administer glucocorticoids intramuscularly
• C. Assess the odor of the amniotic fluid
• D. Prepare the client for emergency cesarean section

Correct answer: C: Assess the odor of the amniotic fluid

Rationale: In a pregnant woman with a temperature of 38.9°C (102°F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.

2. During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

• A. Increased urine output
• B. Vaginal discharge
• C. Elevated blood pressure
• D. Joint pain

Correct answer: Elevated blood pressure

Rationale: Preeclampsia is characterized by elevated blood pressure, proteinuria, and sometimes edema. Hypertension is a key sign of preeclampsia, and if present, further evaluation and monitoring are necessary to prevent complications for both the mother and the fetus.

3. A client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?

• A. The client is carrying more than one fetus
• B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid
• C. An excessive amount of amniotic fluid is present
• D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor

Correct answer: C: An excessive amount of amniotic fluid is present

Rationale: Polyhydramnios refers to the presence of an excessive amount of amniotic fluid around the fetus. This condition can result from various causes, such as maternal diabetes, fetal anomalies, or genetic disorders. It can lead to complications during pregnancy and delivery, such as preterm labor, placental abruption, or fetal malpresentation. Understanding this diagnosis is crucial for providing appropriate care and monitoring to ensure the best outcomes for both the mother and the fetus.

4. A healthcare provider is preparing to administer an injection of Rho (D) immunoglobulin. The provider should understand that the purpose of this injection is to prevent which of the following newborn complications?

• A. Hydrops fetalis
• B. Hypobilirubinemia
• C. Biliary atresia
• D. Transient clotting difficulties

Correct answer: Hydrops fetalis

Rationale: Rho (D) immunoglobulin is given to Rh-negative individuals to prevent hemolytic disease of the newborn (HDN) caused by Rh incompatibility between the mother and the fetus. If an Rh-negative mother carries an Rh-positive fetus, there is a risk of sensitization during pregnancy or childbirth. Sensitization can lead to the production of antibodies that may attack Rh-positive red blood cells in future pregnancies, potentially causing severe hemolytic disease in the newborn, including complications like hydrops fetalis. Hydrops fetalis is a condition characterized by severe edema and fetal organ enlargement due to severe anemia and heart failure in the fetus.

5. When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: Respiratory acidosis

Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.

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