Nursing Elites

1. While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

• A. Place the client in the Trendelenburg position
• B. Apply finger pressure to the presenting part
• C. Administer oxygen at 10 L/min via a non-rebreather
• D. Call for assistance

Correct answer: D

Rationale: In the scenario of umbilical cord prolapse during labor, the nurse should first call for assistance. Umbilical cord prolapse is a critical obstetric emergency that requires immediate attention and skilled assistance. Calling for help ensures that additional support is on the way to provide prompt intervention. Placing the client in the Trendelenburg position (Choice A) is no longer recommended as it may worsen the situation. Applying finger pressure to the presenting part (Choice B) can further compress the cord. Administering oxygen (Choice C) is important but should come after addressing the prolapsed cord.

2. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

• A. Fetal attitude is in general flexion.
• B. Fetal lie is longitudinal.
• C. Maternal pelvis is gynecoid.
• D. Fetal position is persistent occiput posterior.

Correct answer: D

Rationale: The correct answer is D. In a persistent occiput posterior position, the baby's head presses against the mother's spine, causing prolonged labor and severe backache. This position can lead to difficulties in labor progress and increase discomfort for the mother. Choices A, B, and C are incorrect as they do not directly relate to the client's difficult, prolonged labor with severe backache. Fetal attitude, fetal lie, and maternal pelvis type may affect labor, but in this scenario, the persistent occiput posterior fetal position is the primary contributing cause for the client's symptoms.

3. During the admission assessment of a newborn, which anatomical landmark should be used for measuring the newborn's chest circumference?

• A. Sternal notch
• B. Nipple line
• C. Xiphoid process
• D. Fifth intercostal space

Correct answer: B

Rationale: When measuring a newborn's chest circumference, the appropriate anatomical landmark to use is the nipple line. This point is consistent and allows for accurate and standardized measurements across all newborn assessments. The sternal notch is not typically used for chest circumference measurements in newborns. The xiphoid process is located at the lower end of the sternum and is not an appropriate landmark for chest circumference measurement. The fifth intercostal space is typically used for locating the point of maximal impulse (PMI) during cardiac assessments, not for measuring chest circumference.

4. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

• A. The newborn will have decreased muscle tone.
• B. The newborn will have a continuous high-pitched cry.
• C. The newborn will sleep for 2 to 3 hours after a feeding.
• D. The newborn will have mild tremors when disturbed.

Correct answer: B

Rationale: The correct answer is B. A continuous high-pitched cry is a characteristic sign of neonatal abstinence syndrome, indicating withdrawal from drugs. Choices A, C, and D are incorrect because decreased muscle tone, sleeping for 2 to 3 hours after a feeding, and mild tremors when disturbed are not specific indicators of neonatal abstinence syndrome.

5. When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?

• A. Vaginal bleeding
• B. Swelling of the ankles
• C. Heartburn after eating
• D. Lightheadedness when lying on back

Correct answer: A

Rationale: Vaginal bleeding during pregnancy is a concerning sign that could indicate serious complications like miscarriage or placental issues. Prompt reporting to the healthcare provider is crucial for timely evaluation and management to ensure the best outcomes for both the mother and the baby. Swelling of the ankles (choice B), heartburn after eating (choice C), and lightheadedness when lying on the back (choice D) are common discomforts during pregnancy but are not typically associated with serious complications that require immediate attention.

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