Nursing Elites

1. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?

• A. Perform a sharp hand clap near the infant.
• B. Hold the newborn vertically allowing one foot to touch the table surface.
• C. Place a finger at the base of the newborn's toes.
• D. Turn the newborn's head quickly to one side.

Correct answer: A

Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.

2. A client who is pregnant states that her last menstrual period was April 1st. What is the client's estimated date of delivery?

• A. January 8
• B. January 15
• C. February 8
• D. February 15

Correct answer: A

Rationale: To calculate the estimated date of delivery, add 7 days to the first day of the last menstrual period (April 1st), which gives April 8th. Then, count forward 9 months from April 8th, leading to January 8th as the estimated date of delivery. Choice A is correct. Choice B is incorrect because it is exactly 9 months from the last menstrual period without accounting for the additional 7 days. Choices C and D are incorrect as they fall in February, which is beyond the 9-month period from the last menstrual period.

3. During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?

• A. It is used to stimulate uterine contractions.
• B. It will decrease the incidence of uterine contractions.
• C. It lulls the fetus to sleep.
• D. It awakens a sleeping fetus.

Correct answer: D

Rationale: The acoustic vibration device is utilized during a nonstress test to awaken a sleeping fetus. This action helps ensure more accurate test results by eliciting fetal movements and heart rate accelerations, which are indicators of fetal well-being. Choices A, B, and C are incorrect because the primary purpose of the acoustic vibration device during a nonstress test is not to stimulate uterine contractions, decrease uterine contractions, or lull the fetus to sleep. Instead, it is specifically used to awaken a sleeping fetus to assess fetal well-being.

4. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

• A. Maternal/newborn blood group incompatibility
• B. Absence of vitamin K
• C. Physiologic jaundice
• D. Maternal cocaine abuse

Correct answer: A

Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.

5. A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

• A. A client who is experiencing fetal death at 32 weeks of gestation
• B. A client who is experiencing preterm labor at 26 weeks of gestation
• C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
• D. A client who has a post-term pregnancy at 42 weeks of gestation

Correct answer: B

Rationale: Tocolytic therapy is used to suppress premature labor. It is appropriate to administer it to a client experiencing preterm labor at 26 weeks of gestation to help delay delivery and improve neonatal outcomes. Administering tocolytic therapy to a client experiencing fetal death, Braxton-Hicks contractions, or post-term pregnancy is not indicated and may not be safe or effective in these situations. Fetal death at 32 weeks indicates a non-viable pregnancy, Braxton-Hicks contractions are normal and not indicative of preterm labor, and post-term pregnancy at 42 weeks does not require tocolytic therapy.

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