Nursing Elites

1. When should a provider order a maternal serum alpha-fetoprotein (MSAFP) screening for pregnant clients?

• A. A client who has mitral valve prolapse
• B. A client who has been exposed to AIDS
• C. All pregnant clients
• D. A client who has a history of preterm labor

Correct answer: C

Rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is recommended for all pregnant clients to assess the risk of neural tube defects. It is a routine screening test used to detect increased levels of alpha-fetoprotein in maternal blood, which may indicate a higher risk for conditions such as neural tube defects in the developing fetus. Therefore, all pregnant clients, regardless of their medical history or risk factors, should undergo MSAFP screening as part of routine prenatal care. Choices A, B, and D are incorrect because the MSAFP screening is not specific to certain medical conditions or histories; it is a standard screening procedure for all pregnant individuals to evaluate neural tube defect risk in the fetus.

2. When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?

• A. Babinski
• B. Rooting
• C. Moro
• D. Stepping

Correct answer: B

Rationale: The correct answer is B: Rooting. The rooting reflex is crucial in newborns as it helps them locate the nipple for feeding. This reflex involves turning the head towards a stimulus that touches the cheek or mouth, aiding in the process of latching onto the breast for breastfeeding. The Babinski reflex is the fanning out and curling of the toes when the sole of the foot is stroked, the Moro reflex is the startle reflex in response to a sudden noise or movement, and the stepping reflex is the appearance of taking steps when an infant is held upright with feet touching a solid surface. Therefore, choices A, C, and D are incorrect as they do not play a direct role in promoting a newborn to latch during breastfeeding.

3. A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?

• A. Persistent abdominal striae
• B. Temperature 37.8° C (100.2° F)
• C. Unilateral breast pain
• D. Brownish-red discharge on day 5

Correct answer: C

Rationale: Unilateral breast pain can be a sign of mastitis, an infection of the breast tissue, which requires prompt evaluation and treatment. The nurse should instruct the client to report this clinical manifestation to the provider to prevent complications and promote recovery.

4. A client is scheduled for a cesarean birth based on fetal lung maturity. Which finding indicates that the fetal lungs are mature?

• A. Absence of Phosphatidylglycerol (PG)
• B. Biophysical profile score of 8
• C. Lecithin/sphingomyelin (L/S) ratio of 2:1
• D. Reactive nonstress test

Correct answer: C

Rationale: An L/S ratio of 2:1 indicates fetal lung maturity, as it signifies the presence of surfactant in the amniotic fluid, which helps with lung expansion and prevents collapse at the end of expiration. The absence of PG indicates immaturity of the fetal lungs, as PG appears in the amniotic fluid during the later stages of lung maturation. Biophysical profile scores and nonstress tests are assessments of fetal well-being and do not directly indicate fetal lung maturity. Therefore, choice C is the correct answer.

5. A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

• A. Assess deep tendon reflexes every hour.
• B. Obtain a daily weight.
• C. Continuous fetal monitoring
• D. Ambulate twice daily

Correct answer: D

Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.

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