Nursing Elites

1. A newborn is 1 hour old with a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F). Which of the following actions should be taken?

• A. Give the newborn a warm bath.
• B. Apply a cap to the newborn's head.
• C. Reposition the newborn.
• D. Obtain an oxygen saturation level.

Correct answer: B

Rationale: Applying a cap to the newborn's head is the correct action in this scenario. Newborns are at risk of heat loss due to their high surface area to volume ratio, and maintaining their body temperature is crucial to prevent hypothermia. Giving a warm bath can further increase heat loss and is not recommended. Repositioning the newborn may not address the primary concern of temperature regulation. While monitoring oxygen saturation is important, addressing thermal regulation takes precedence in this situation.

2. A client at 38 weeks of gestation has a prescription for intravaginal misoprostol. Which of the following statements should the nurse make?

• A. “You will need to stay in a side-lying position for 30 minutes after each dose.”
• B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.”
• C. “You will receive a magnesium supplement immediately following therapy.”
• D. “You will need to have a full bladder before the therapy begins.”

Correct answer: A

Rationale: The correct answer is A. Instructing the client to stay in a side-lying position after receiving misoprostol intravaginally is essential. This position helps keep the medication in place, allowing for better absorption. Choice B is incorrect because oxytocin administration is not typically indicated after misoprostol use. Choice C is incorrect as magnesium supplementation is not part of the standard protocol for misoprostol administration. Choice D is incorrect as having a full bladder is not necessary before initiating misoprostol therapy.

3. What is the typical sex chromosome pattern for females?

• A. XX
• B. XYY
• C. XY
• D. XXY

Correct answer: A

Rationale: The typical sex chromosome pattern for females is XX. Females have two X chromosomes, which is represented as XX. Choice B (XYY) is incorrect as it represents the sex chromosome pattern for males with an extra Y chromosome. Choice C (XY) is the sex chromosome pattern for males. Choice D (XXY) represents a genetic disorder known as Klinefelter syndrome, where males have an extra X chromosome.

4. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

• A. Assess the blood pressure for hypertension.
• B. Gently massage fundus every four hours.
• C. Observe for signs of uterine hemorrhage.
• D. Encourage direct contact with the infant.

Correct answer: C

Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.

5. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?

• A. Uterine atony.
• B. Uterine inversion.
• C. Vaginal hematoma.
• D. Vaginal laceration.

Correct answer: A

Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.

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