Nursing Elites

1. A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?

• A. This test screens for neural tube defects and other developmental abnormalities in the fetus.
• B. It assesses various markers of fetal well-being.
• C. This test identifies an Rh incompatibility between the mother and fetus.
• D. It is a screening test for spinal defects in the fetus.

Correct answer: A

Rationale: The maternal serum alpha-fetoprotein (MSAFP) test is performed around 15-18 weeks of gestation to screen for neural tube defects and other developmental abnormalities in the fetus, not to assess fetal lung maturity, markers of fetal well-being, or Rh incompatibility between the mother and fetus. Choice A is the correct answer as it accurately reflects the purpose of the MSAFP test. Choices B, C, and D are incorrect because they do not align with the primary goal of this screening test.

2. During preterm labor, a client is scheduled for an amniocentesis. The nurse should review which of the following tests to assess fetal lung maturity?

• A. Alpha-fetoprotein (AFP)
• B. Lecithin/sphingomyelin (L/S) ratio
• C. Kleihauer-Betke test
• D. Indirect Coombs' test

Correct answer: B

Rationale: The Lecithin/sphingomyelin (L/S) ratio is a test used to evaluate fetal lung maturity. An L/S ratio greater than 2:1 indicates fetal lung maturity. This test helps in determining the risk of respiratory distress syndrome in the newborn. Alpha-fetoprotein (AFP) is used in screening for neural tube defects, not for assessing lung maturity. The Kleihauer-Betke test is used to detect fetal-maternal hemorrhage, not fetal lung maturity. The Indirect Coombs' test is used to identify the presence of antibodies in the mother's blood that could attack fetal red blood cells, not for assessing lung maturity.

3. A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

• A. The client's room number
• B. The client's telephone number
• C. The client's birth date
• D. The client's medical record number

Correct answer: A

Rationale: The correct answer is A. Using the client's room number as a secondary identifier is not an appropriate method for client identification in healthcare settings. It can lead to confusion and potential errors, especially in a busy environment like a postpartum unit. Room numbers are not unique to individual patients and can change frequently. Instead, healthcare providers should use more reliable and specific identifiers like the client's name, medical record number, or date of birth to ensure accurate identification and safe administration of medications. Choices B, C, and D are more appropriate secondary identifiers for client identification as they are more specific and less prone to errors than room numbers.

4. A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?

• A. Active
• B. Transition
• C. Latent
• D. Descent

Correct answer: B

Rationale: The client is in the transition phase of labor, characterized by cervical dilatation of 8 to 10 cm and contractions every 2 to 3 minutes, each lasting 45 to 90 seconds. In this phase, the cervix is nearly fully dilated, preparing the client for the pushing stage. The active phase of labor typically involves cervical dilatation from 4 to 7 cm, whereas the latent phase is the early phase of labor when the cervix dilates from 0 to 3 cm. Descent is not a phase of labor but rather refers to the movement of the fetus through the birth canal during the second stage of labor.

5. A healthcare professional is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the healthcare professional anticipate administering?

• A. Ofloxacin
• B. Nystatin
• C. Erythromycin
• D. Ceftriaxone

Correct answer: C

Rationale: Erythromycin eye ointment is the medication of choice for preventing ophthalmia neonatorum, an eye infection in newborns caused by exposure to gonorrhea or chlamydia during birth. Erythromycin helps prevent the transmission of these bacteria from the mother to the baby during delivery, protecting the newborn's eyes from potential infection. Ofloxacin, Nystatin, and Ceftriaxone are not indicated for preventing ophthalmia neonatorum. Ofloxacin is a fluoroquinolone antibiotic used for treating eye infections in adults, Nystatin is an antifungal medication used for fungal infections, and Ceftriaxone is a cephalosporin antibiotic used for various bacterial infections, but not for preventing ophthalmia neonatorum.

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