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. When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?

• A. Blood-tinged sputum
• B. Dizziness
• C. Pallor
• D. Somnolence

Correct answer: B

Rationale: Corrected Question: When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations? Rationale: Nifedipine, a calcium channel blocker, causes vasodilation, potentially leading to a decrease in blood pressure and side effects such as dizziness. Monitoring for dizziness is essential to ensure the client's safety and well-being during treatment. Choices A, C, and D are incorrect as they are not typically associated with nifedipine use for preventing preterm labor. Blood-tinged sputum may indicate other conditions like pulmonary issues, pallor could suggest anemia or circulatory problems, and somnolence is not a common side effect of nifedipine.

3. A client who is at 39 weeks of gestation and is in active labor has fetal heart tones located above the umbilicus at midline. The fetus is likely in which of the following positions?

• A. Cephalic
• B. Transverse
• C. Posterior
• D. Frank breech

Correct answer: D

Rationale: Fetal heart tones above the umbilicus at midline are indicative of a breech presentation, specifically a frank breech position. In a frank breech position, the baby's buttocks are presenting first, which aligns with the fetal heart tones being above the umbilicus. This position indicates that the baby is not in the normal head-down position for birth, which can impact the delivery process and may require specific interventions. Cephalic presentation (Choice A) is the normal head-down position for birth, transverse lie (Choice B) is when the baby is positioned horizontally in the uterus, and posterior position (Choice C) refers to the baby's back being positioned towards the mother's back.

4. 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.

5. A client in labor is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

• A. Contractions that last for 60 seconds each with a 4-minute rest between contractions
• B. A contraction that lasts 4 minutes followed by a period of relaxation
• C. Contractions that last for 60 seconds each with a 3-minute rest between contractions
• D. Contractions that last 45 seconds each with a 3-minute rest between contractions

Correct answer: C

Rationale: The correct answer is C. When contractions are 4 minutes apart, it means there are 4 minutes from the start of one contraction to the start of the next. If each contraction lasts 60 seconds, there will be a 3-minute rest period between contractions. This allows for adequate uterine relaxation and recovery before the next contraction begins. Choice A is incorrect because it suggests a 4-minute rest between contractions, which is not accurate. Choice B is incorrect as contractions lasting 4 minutes continuously without rest would be concerning. Choice D is incorrect as it suggests 45-second contractions instead of 60-second contractions.

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