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 client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?

• A. This is due to an increase in blood volume.
• B. This is due to pressure from the uterus on the diaphragm.
• C. This is due to the weight of the uterus on the vena cava.
• D. This is due to increased cardiac output.

Correct answer: C

Rationale: Maternal hypotension during pregnancy is often caused by the weight of the uterus pressing on the vena cava when the client is lying on her back, which reduces blood flow to the heart. This compression can lead to a decrease in blood pressure and subsequent symptoms of hypotension. Choice A is incorrect because an increase in blood volume typically leads to increased blood pressure rather than hypotension. Choice B is incorrect as pressure from the uterus on the diaphragm is not a common cause of maternal hypotension. Choice D is incorrect because increased cardiac output would not directly cause maternal hypotension.

3. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

• A. Check the client's temperature.
• B. Observe for uterine contractions.
• C. Administer Rho(D) immune globulin.
• D. Monitor the fetal heart rate (FHR).

Correct answer: D

Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.

4. When checking for the Moro reflex in a newborn, what action should the nurse take?

• A. Hold the newborn vertically under arms and allow one foot to touch the table.
• B. Stimulate the pads of the newborn's hands with stroking or massage.
• C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
• D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.

Correct answer: D

Rationale: The correct action to check for the Moro reflex in a newborn is to hold the newborn in a semi-sitting position and then allow the newborn's head and trunk to fall backward. The Moro reflex is elicited by a sudden loss of support or a loud noise. The normal response involves symmetrical abduction and extension of the arms, followed by their return to the midline in an embracing motion. Choices A, B, and C do not describe the correct method for assessing the Moro reflex and are therefore incorrect.

5. A client who is at 22 weeks gestation is being educated by a nurse about the amniocentesis procedure. Which of the following statements should the nurse make?

• A. You will lie on your right side during the procedure.
• B. You should not eat anything for 24 hours before the procedure.
• C. You should empty your bladder before the procedure.
• D. The test is performed to determine gestational age.

Correct answer: C

Rationale: The correct answer is C. The nurse should advise the client to empty her bladder before an amniocentesis to minimize the risk of bladder puncture during the procedure. This precaution helps ensure the safety and accuracy of the procedure by reducing potential complications related to bladder puncture. Choices A, B, and D are incorrect because lying on the right side, fasting for 24 hours, and determining gestational age are not relevant instructions for an amniocentesis procedure.

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